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Tomlinson C, Haiek LN. Breastfeeding and human milk in the NICU: From birth to discharge. Paediatr Child Health 2023; 28:510-526. [PMID: 38638537 PMCID: PMC11022875 DOI: 10.1093/pch/pxad034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 04/20/2022] [Indexed: 04/20/2024] Open
Abstract
It is well recognized that human milk is the optimal nutritive source for all infants, including those requiring intensive care. This statement reviews evidence supporting the importance of breastfeeding and human milk for infants, and why breastfeeding practices should be prioritized in the neonatal intensive care unit (NICU). It also reviews how to optimally feed infants based on their stability and maturity, and how to support mothers to establish and maintain milk production when their infants are unable to feed at the breast.
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Affiliation(s)
- Christopher Tomlinson
- Canadian Paediatric Society, Nutrition and Gastroenterology Committee, Ottawa, Ontario, Canada
| | - Laura N Haiek
- Canadian Paediatric Society, Nutrition and Gastroenterology Committee, Ottawa, Ontario, Canada
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2
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Aloysius A, Bell N, Canning A, Ferrara-Gonzalez L, Marks J, Murphy R, Norburn K, Parnell K, Harding C. RCSLT Neonatal CEN Response to ESPGHAN Preterm Enteral Nutrition Position Paper (2022)-Issues of Oral Feeding on CPAP. J Pediatr Gastroenterol Nutr 2023; 77:e71. [PMID: 37580855 DOI: 10.1097/mpg.0000000000003915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Affiliation(s)
- Annie Aloysius
- From Imperial College Healthcare NHS Trust, RCSLT Neonatal CEN (chair), UK
| | | | - Angie Canning
- Gold Coast University Hospital, Queensland, Australia
| | | | - Jo Marks
- Manchester Foundation Trust, Manchester, UK
| | | | | | - Katy Parnell
- Birmingham Women's and Children's NHS Foundation Trust, Lead Neonatal Network SLT West Midlands Neonatal Operational Delivery Network, Birmingham, UK
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3
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Barnes C, Herbert TL, Bonilha HS. Parameters for Orally Feeding Neonates Who Require Noninvasive Ventilation: A Systematic Review. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2023:1-20. [PMID: 37098117 DOI: 10.1044/2023_ajslp-22-00259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
PURPOSE Infants hospitalized in the neonatal intensive care unit (NICU) may be orally fed while receiving noninvasive ventilation (NIV), but the practice is variable and decision criteria are not well understood. This systematic review examines the evidence regarding this practice, including type and level of NIV used during NICU oral feeding, protocols, and safety of this practice. METHOD The PubMed, Scopus, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched to identify publications relevant to this review. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to ensure the appropriate inclusion of articles. RESULTS Fourteen articles were included. Seven studies (50%) were retrospective. Two were quality improvement projects, and the remaining five (35.7%) were prospective. Continuous positive airway pressure and high-flow nasal cannula were commonly used. Levels of respiratory support were variable between studies, if reported at all. Three studies (21.4%) included feeding protocols. Six studies (42.9%) identified use of feeding experts. While many studies commented that orally feeding neonates on NIV is safe, the only study to instrumentally assess swallow safety found that a significant number of neonates silently aspirated during feeding on continuous positive airway pressure. CONCLUSIONS Strong data supporting practices related to orally feeding infants in the NICU who require NIV are scarce. The types and levels of NIV, and decision-making criteria, are variable across studies and preclude clinically useful conclusions. There is a pressing need for additional research pertaining to orally feeding this population so that an evidence-based standard of care can be established. Specifically, this research should elucidate the impact of different types and levels of NIV on the mechanistic properties of swallowing as defined via instrumental assessment.
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Affiliation(s)
- Carolyn Barnes
- Department of Health Sciences & Research, Medical University of South Carolina, Charleston
| | - Teri Lynn Herbert
- Academic Affairs Faculty, Medical University of South Carolina, Charleston
| | - Heather S Bonilha
- Department of Health Sciences & Research, Medical University of South Carolina, Charleston
- Department of Rehabilitation Medicine, Emory University, Atlanta, GA
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4
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Ramdas D, Drury N, Jordan C, Panda S, Singh AP. Effects of Infant Driven Feeding Program on Provision of Breast Milk in Very Low Birth Weight Infants. Breastfeed Med 2023; 18:272-278. [PMID: 36848267 DOI: 10.1089/bfm.2022.0212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Background: The ability to complete nipple feedings is one of the discharge criteria for most premature neonates. The Infant Driven Feeding (IDF) program suggests a system of objective promotion of oral feeds in premature infants. There is a lack of studies systematically studying the effects of IDF on the provision of breast milk. Methods: This was a retrospective study of all premature infants born before 33 weeks and birth weight of <1,500 g admitted to a level IV neonatal intensive care unit. Infants on IDF were compared with those not on IDF. Results: A total of 46 infants in the IDF group and 52 in the non-IDF group met the inclusion criteria. A higher number of infants in the IDF group breastfed at first oral attempt (54% versus 12%). Forty-five percent of IDF mothers completed a full 72 hours of protected breastfeeding at the start of oral feeds, and IDF infants had earlier removal of nasogastric (NG) tube. There was no difference in the provision of breast milk and/or breastfeeding on discharge between the two groups. There was no difference in the length of stay between the two groups. Conclusion: The IDF program attempts to streamline the promotion of oral feeds in very low birth weight infants. Higher incidence of breastfeeding at the start of oral feeds and earlier removal of NG tube did not translate into higher provision of breast milk on discharge in very low birth weight infants in the IDF group. Prospective randomized trials are needed to validate cue-based infant driven feeding programs and their effects on the provision of breast milk.
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Affiliation(s)
- Divya Ramdas
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, Texas, USA
| | - Nicole Drury
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, Texas, USA
| | - Carmesha Jordan
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, Texas, USA
| | - Sanjeet Panda
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, Texas, USA.,El Paso Children's Hospital, El Paso, Texas, USA
| | - Ajay Pratap Singh
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, Texas, USA.,El Paso Children's Hospital, El Paso, Texas, USA
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Embleton ND, Jennifer Moltu S, Lapillonne A, van den Akker CHP, Carnielli V, Fusch C, Gerasimidis K, van Goudoever JB, Haiden N, Iacobelli S, Johnson MJ, Meyer S, Mihatsch W, de Pipaon MS, Rigo J, Zachariassen G, Bronsky J, Indrio F, Köglmeier J, de Koning B, Norsa L, Verduci E, Domellöf M. Enteral Nutrition in Preterm Infants (2022): A Position Paper From the ESPGHAN Committee on Nutrition and Invited Experts. J Pediatr Gastroenterol Nutr 2023; 76:248-268. [PMID: 36705703 DOI: 10.1097/mpg.0000000000003642] [Citation(s) in RCA: 51] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
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.
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Affiliation(s)
| | | | | | - Chris H P van den Akker
- the Department of Pediatrics - Neonatology, Amsterdam UMC - Emma Children's Hospital, University of Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Virgilio Carnielli
- Polytechnic University of Marche and Division of Neonatology, Ospedali Riuniti, Ancona, Ancona, Italy
| | - Christoph Fusch
- the Department of Pediatrics, Nuremberg General Hospital, Paracelsus Medical School, Nuremberg, Germany
- the Division of Neonatology, Department of Pediatrics, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Konstantinos Gerasimidis
- the Human Nutrition, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - Johannes B van Goudoever
- Amsterdam UMC, University of Amsterdam, Vrije Universiteit, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Nadja Haiden
- the Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Silvia Iacobelli
- the Réanimation Néonatale et Pédiatrique, Néonatologie - CHU La Réunion, Saint-Pierre, France
| | - Mark J Johnson
- the Department of Neonatal Medicine, University Hospital Southampton NHS Trust, Southampton, UK
- the National Institute for Health Research Biomedical Research Centre Southampton, University Hospital Southampton NHS Trust and University of Southampton, Southampton, UK
| | - Sascha Meyer
- the Department of General Paediatrics and Neonatology, University Hospital of Saarland, Homburg, Germany
| | - Walter Mihatsch
- the Department of Pediatrics, Ulm University, Ulm, Germany
- the Department of Health Management, Neu-Ulm University of Applied Sciences, Neu-Ulm, Germany
| | - Miguel Saenz de Pipaon
- the Department of Pediatrics-Neonatology, La Paz University Hospital, Autonoma University of Madrid, Madrid, Spain
| | - Jacques Rigo
- the Neonatal Unit, University of Liège, CHR Citadelle, Liège, Belgium
| | - Gitte Zachariassen
- H.C. Andersen Children's Hospital, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Jiri Bronsky
- the Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
| | - Flavia Indrio
- the Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Jutta Köglmeier
- the Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Barbara de Koning
- the Paediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Lorenzo Norsa
- the Paediatric Hepatology, Gastroenterology and Transplantation, ASST Papa Giovanni XXIIII, Bergamo, Italy
| | - Elvira Verduci
- the Department of Health Sciences, University of Milan, Milan, Italy
- the Department of Paediatrics, Ospedale dei Bambini Vittore Buzzi, Milan, Italy
| | - Magnus Domellöf
- the Department of Clinical Sciences, Paediatrics, Umeå University, Umeå, Sweden
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Mamidi RR, MacDonald KD, Brumbach BH, Go MDA, McEvoy CT. Nasal continuous positive airway pressure practices in preterm infants: A survey of neonatal providers. J Neonatal Perinatal Med 2023; 16:611-617. [PMID: 38043019 DOI: 10.3233/npm-230006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
BACKGROUND The standard of care for respiratory support of preterm infants is nasal continuous positive airway pressure (CPAP), yet practices are not standardized. Our aim was to survey CPAP practices in infants < 32 weeks gestation among the American Academy of Pediatrics Neonatal-Perinatal section. METHODS A US, web-based survey inquired about the initiation, management, and discontinuation of CPAP, and chinstrap use and oral feedings on CPAP. RESULTS 857 providers consented. Regarding criteria to discontinue/wean CPAP: 69% use specific respiratory stability criteria; 22% a specific post-menstrual age; 8% responded other. 64% did not have guidelines for CPAP discontinuation; 54% did not have guidelines for CPAP initiation. 66% believe chinstraps improve CPAP efficacy; however, 11% routinely apply a chinstrap. 22% allow oral feeds on CPAP in certain circumstances. CONCLUSION There are meaningful variabilities in CPAP practices among neonatal providers across the US. Given the potential long-term implications this can have on the growth and development of the preterm lung, further evidence-based research is needed in relation to respiratory outcomes to optimize and standardize CPAP strategies.
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Affiliation(s)
- R R Mamidi
- Division of Neonatology, Oregon Health & Science University, Portland, OR, USA
| | - K D MacDonald
- Division of Pediatric Pulmonology, Oregon Health & Science University, Portland, OR, USA
| | - B H Brumbach
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR, USA
| | - M D A Go
- Division of Neonatology, Oregon Health & Science University, Portland, OR, USA
| | - C T McEvoy
- Division of Neonatology, Oregon Health & Science University, Portland, OR, USA
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Hasenstab KA, Jadcherla SR. Evidence-Based Approaches to Successful Oral Feeding in Infants with Feeding Difficulties. Clin Perinatol 2022; 49:503-520. [PMID: 35659100 DOI: 10.1016/j.clp.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Infants in the neonatal intensive care unit (NICU) frequently have feeding difficulties with the root cause remaining elusive to identify. Evaluation of the provider/parent/infant feeding process may provide objective clues to sources of feeding difficulty. Specialized testing may be necessary to determine if the infant's swallowing skills are dysfunctional, immature, or maldeveloped, and to determine the risk of feeding failure or chronic tube feeding. Current evidence-based diagnostic and management approaches resulting in successful oral feeding in the NICU infant are discussed.
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Affiliation(s)
- Kathryn A Hasenstab
- Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, 575 Children's Crossroads, Columbus, OH 43215, USA
| | - Sudarshan R Jadcherla
- Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, 575 Children's Crossroads, Columbus, OH 43215, USA; Division of Neonatology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Division Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Pediatrics, The Ohio State University College of Medicine, 370 W 9th Ave, Columbus, OH 43210, USA.
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Pavlek LR, Mueller C, Jebbia MR, Kielt MJ, Nelin LD, Shepherd EG, Reber KM, Fathi O. Perspectives on developing and sustaining a small baby program. Semin Perinatol 2022; 46:151548. [PMID: 34895927 DOI: 10.1016/j.semperi.2021.151548] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The Small Baby Program at Nationwide Children's Hospital was launched in 2004 in response to a need for better care for infants born extremely preterm. Standardization of care, decreased variability, multidisciplinary support, and robust research and quality improvement have allowed us to greatly improve our outcomes. In addition to the numerous medical and technological advances during this time, a strong commitment to kangaroo care and family-centered care have been integral to the growth and success of our program. The following review of the program aims to highlight the above areas while detailing the specific processes that have contributed to its ongoing success. Key areas of focus have been on respiratory management, neurodevelopmental care, and nutritional optimization. The implementation and continued refinement of the Small Baby Program has allowed us to improve the survival of extremely preterm infants, decrease certain morbidities, and improve long-term neurodevelopmental outcomes.
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Affiliation(s)
- Leeann R Pavlek
- Small Baby ICU, Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States; Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, 575 Children's Crossroad, Columbus, OH 43205, United States.
| | - Clifford Mueller
- Small Baby ICU, Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Maria R Jebbia
- Small Baby ICU, Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Matthew J Kielt
- Small Baby ICU, Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Leif D Nelin
- Small Baby ICU, Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States; Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, 575 Children's Crossroad, Columbus, OH 43205, United States
| | - Edward G Shepherd
- Small Baby ICU, Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Kristina M Reber
- Small Baby ICU, Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Omid Fathi
- Small Baby ICU, Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
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Heo JS, Kim EK, Kim SY, Song IG, Yoon YM, Cho H, Lee ES, Shin SH, Oh BM, Shin HI, Kim HS. Direct swallowing training and oral sensorimotor stimulation in preterm infants: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed 2022; 107:166-173. [PMID: 34281934 DOI: 10.1136/archdischild-2021-321945] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/21/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To evaluate the effects of direct swallowing training (DST) alone and combined with oral sensorimotor stimulation (OSMS) on oral feeding ability in very preterm infants. DESIGN Blinded, parallel group, randomised controlled trial (1:1:1). SETTING Neonatal intensive care unit of a South Korean tertiary hospital. PARTICIPANTS Preterm infants born at <32 weeks of gestation who achieved full tube feeding. INTERVENTIONS Two sessions per day were provided according to the randomly assigned groups (control: two times per day sham intervention; DST: DST and sham interventions, each once a day; DST+OSMS: DST and OSMS interventions, each once a day). PRIMARY OUTCOME Time from start to independent oral feeding (IOF). RESULTS Analyses were conducted in 186 participants based on modified intention-to-treat (63 control; 63 DST; 60 DST+OSMS). The mean time from start to IOF differed significantly between the control, DST and DST+OSMS groups (21.1, 17.2 and 14.8 days, respectively, p=0.02). Compared with non-intervention, DST+OSMS significantly shortened the time from start to IOF (effect size: -0.49; 95% CI: -0.86 to -0.14; p=0.02), whereas DST did not. The proportion of feeding volume taken during the initial 5 min, an index of infants' actual feeding ability when fatigue is minimal, increased earlier in the DST+OSMS than in the DST. CONCLUSIONS In very preterm infants, DST+OSMS led to the accelerated attainment of IOF compared with non-intervention, whereas DST alone did not. The effect of DST+OSMS on oral feeding ability appeared earlier than that of DST alone. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT02508571).
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Affiliation(s)
- Ju Sun Heo
- Department of Paediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of).,Department of Paediatrics, Korea University Anam Hospital, Seoul, Korea (the Republic of)
| | - Ee-Kyung Kim
- Department of Paediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
| | - Sae Yun Kim
- Department of Paediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of).,Department of Paediatrics, Catholic University of Korea Yeouido Saint Mary's Hospital, Seoul, Korea (the Republic of)
| | - In Gyu Song
- Department of Paediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of).,Department of Paediatrics, Korea University Guro Hospital, Seoul, Korea (the Republic of)
| | - Young Mi Yoon
- Department of Paediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of).,Department of Paediatrics, Jeju National University Hospital, Jeju, Korea (the Republic of)
| | - Hannah Cho
- Department of Paediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of).,Department of Paediatrics, Korea University Anam Hospital, Seoul, Korea (the Republic of)
| | - Eun Sun Lee
- Department of Paediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of).,Department of Paediatrics, Chung-Ang University Hospital, Seoul, Korea (the Republic of)
| | - Seung Han Shin
- Department of Paediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
| | - Byung-Mo Oh
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul, Korea (the Republic of).,Department of Rehabilitation Medicine, National Traffic Injury Rehabilitation Hospital, Yangpyeong, Korea (the Republic of).,Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul, Korea (the Republic of)
| | - Hyung-Ik Shin
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul, Korea (the Republic of).,Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul, Korea (the Republic of)
| | - Han-Suk Kim
- Department of Paediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
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10
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Schwab ME, Crennan M, Burke S, Sang H, Klarich MK, Keller RL, Vu LT. Oral Feeding in Infants After Congenital Diaphragmatic Hernia Repair While on Non-invasive Positive Pressure Ventilation: The Impact of a Dysphagia Provider-Led Protocol. Dysphagia 2022; 37:1305-1313. [PMID: 34981254 DOI: 10.1007/s00455-021-10391-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 11/22/2021] [Indexed: 11/03/2022]
Abstract
Infants with congenital diaphragmatic hernia (CDH) who require non-invasive positive pressure ventilation or high flow nasal cannula are at risk for aspiration and delayed initiation of oral feeding. We developed a dysphagia provider-led protocol that involved early consultation with an occupational therapist or speech/language pathologist and modified barium swallow study (MBSS) to assess for readiness for oral feeding initiation/advancement on non-invasive positive pressure ventilation. The objective of this study was to retrospectively compare this intervention cohort to a historical control cohort to evaluate the protocol's impact on the time to initiate oral feeding. We describe the development and implementation of the protocol, the MBSS findings of the intervention cohort, and compared the control (n = 64) and intervention (n = 37) cohorts using Fischer's exact test and Mann-Whitney test. We found that both cohorts had similar prenatal and neonatal characteristics including age at extubation. Significantly more infants in the intervention cohort were on non-invasive positive pressure ventilation or high flow nasal cannula at the time of oral feeding initiation (84% vs. 28%, p < 0.0001). None of the control cohort infants underwent MBSS while on respiratory support. Of the intervention cohort, 15 infants underwent a MBSS while on non-invasive positive pressure ventilation; 6 had no evidence of laryngeal penetration and/or aspiration during swallowing. Infants in the control cohort initiated oral feeds significantly sooner after extubation (6 versus 11 days, p = 0.001) and attained full oral feeds earlier (20 days versus 28 days, p = 0.02) than the intervention group. There was no difference in the rate of gastrostomy tube placement (38%). Appropriate monitoring by a dysphagia provider and evaluation with clinical and radiological means are crucial to determine the safety of initiating oral feeding in term infants with CDH. Continued surveillance is needed to determine the long-term impact on oral feeding progression in this population.
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Affiliation(s)
- Marisa E Schwab
- Division of Pediatric Surgery, University of California San Francisco, San Francisco, CA, USA.
| | - Miriam Crennan
- Department of Occupational Therapy, University of California San Francisco, San Francisco, CA, USA
| | - Shannon Burke
- Department of Nutrition and Food Services, University of California San Francisco, San Francisco, CA, USA
| | - Helen Sang
- Department of Occupational Therapy, University of California San Francisco, San Francisco, CA, USA
| | - Mary Kate Klarich
- Division of Pediatric Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Roberta L Keller
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Lan T Vu
- Division of Pediatric Surgery, University of California San Francisco, San Francisco, CA, USA
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11
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Elsedawi BF, Samson N, Nadeau C, Vanhaverbeke K, Nguyen N, Alain C, Fortin-Pellerin E, Praud JP. Safety of Bottle-Feeding Under Nasal Respiratory Support in Preterm Lambs With and Without Tachypnoea. Front Physiol 2022; 12:785086. [PMID: 35046837 PMCID: PMC8762202 DOI: 10.3389/fphys.2021.785086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/06/2021] [Indexed: 11/19/2022] Open
Abstract
Aim: Convalescing preterm infants often require non-invasive respiratory support, such as nasal continuous positive airway pressure or high-flow nasal cannulas. One challenging milestone for preterm infants is achieving full oral feeding. Some teams fear nasal respiratory support might disrupt sucking–swallowing–breathing coordination and induce severe cardiorespiratory events. The main objective of this study was to assess the safety of oral feeding of preterm lambs on nasal respiratory support, with or without tachypnoea. Methods: Sucking, swallowing and breathing functions, as well as electrocardiogram, oxygen haemoglobin saturation, arterial blood gases and videofluoroscopic swallowing study were recorded in 15 preterm lambs during bottle-feeding. Four randomly ordered conditions were studied: control, nasal continuous positive airway pressure (6 cmH2O), high-flow nasal cannulas (7 L•min–1), and high-flow nasal cannulas at 7 L•min–1 at a tracheal pressure of 6 cmH2O. The recordings were repeated on days 7–8 and 13–14 to assess the effect of maturation. Results: None of the respiratory support impaired the safety or efficiency of oral feeding, even with tachypnoea. No respiratory support systematically impacted sucking–swallowing–breathing coordination, with or without tachypnoea. No effect of maturation was found. Conclusion: This translational physiology study, uniquely conducted in a relevant animal model of preterm infant with respiratory impairment, shows that nasal respiratory support does not impact the safety or efficiency of bottle-feeding or sucking–swallowing–breathing coordination. These results suggest that clinical studies on bottle-feeding in preterm infants under nasal continuous positive airway pressure and/or high-flow nasal cannulas can be safely undertaken.
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Affiliation(s)
- Basma Fathi Elsedawi
- Neonatal Respiratory Research Unit, Department of Pediatrics, Department of Physiology, University of Sherbrooke, Sherbrooke, QC, Canada
- Department of Human Anatomy and Embryology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Nathalie Samson
- Neonatal Respiratory Research Unit, Department of Pediatrics, Department of Physiology, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Charlène Nadeau
- Neonatal Respiratory Research Unit, Department of Pediatrics, Department of Physiology, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Kristien Vanhaverbeke
- Neonatal Respiratory Research Unit, Department of Pediatrics, Department of Physiology, University of Sherbrooke, Sherbrooke, QC, Canada
- Laboratory of Experimental Medicine and Pediatrics, Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium
- Department of Pediatrics, Antwerp University Hospital, Edegem, Belgium
| | - Nam Nguyen
- Neonatal Respiratory Research Unit, Department of Pediatrics, Department of Physiology, University of Sherbrooke, Sherbrooke, QC, Canada
- Faculty of Human Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Charles Alain
- Neonatal Respiratory Research Unit, Department of Pediatrics, Department of Physiology, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Etienne Fortin-Pellerin
- Neonatal Respiratory Research Unit, Department of Pediatrics, Department of Physiology, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Jean-Paul Praud
- Neonatal Respiratory Research Unit, Department of Pediatrics, Department of Physiology, University of Sherbrooke, Sherbrooke, QC, Canada
- *Correspondence: Jean-Paul Praud,
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12
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Osborn EK, Jadcherla SR. Developing a Quality Improvement Feeding Program for NICU Patients. Neoreviews 2022; 23:e23-e35. [PMID: 34970663 DOI: 10.1542/neo.23-1-e23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Practices in NICUs vary widely, particularly when clinical decisions involve complex tasks and multiple disciplines, which occurs with feeding preterm infants. Neonatal feeding difficulties in preterm infants often lead to prolonged tube feeding and therefore lengthened hospital stays. Education and compliance with evidence-based protocols and guidelines are needed on the initiation of feedings and feeding advancement to transform enteral and oral feeding practices and thus reduce practice variation and improve clinical outcomes.
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Affiliation(s)
- Erika K Osborn
- Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Sudarshan R Jadcherla
- Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH.,Divisions of Neonatology and Pediatric Gastroenterology and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
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13
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Anderson E, Gregoski MJ, Gehle D, Head WT, Hardy KT, Chapman A, Ryan RM. Severity of respiratory disease is correlated with time of first oral feeding and need for a gastrostomy tube at discharge in premature infants born at <30 weeks of gestation. Pediatr Pulmonol 2022; 57:193-199. [PMID: 34596360 DOI: 10.1002/ppul.25713] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 08/15/2021] [Accepted: 09/20/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Premature infants who cannot achieve full oral feeds may need a gastrostomy tube (GT) to be discharged from the neonatal intensive care unit (NICU). We previously developed a model to predict which infants born <30 weeks (w) gestational age (GA) will require a GT before discharge. Here we report the detailed respiratory variable data to describe the general respiratory course for infants in the NICU < 30 w GA at birth and the association between different levels of respiratory support with postmenstrual age (PMA) at the time of first oral feeding attempt (PMAff), including later need for GT for discharge. METHODS Retrospective chart review of 391 NICU admissions comprising test (2015-2016) and validation (2017-2018) cohorts. Data, including respiratory support, were collected on 204 infants, 41 GT and 163 non-GT, in the test cohort, and 187 infants, 37 GT, and 150 non-GT, in the validation cohort. RESULTS Respiratory data were significantly different between GT and non-GT infants. Infants who required GT for discharge were on significantly higher respiratory support at 30 days of age, 32 w PMA, and 36 w PMA. Respiratory parameters were highly correlated with PMAff. CONCLUSION Respiratory status predicts PMAff, which was the variable in our previously described model that was most predictive of failure to achieve full oral feeding. These data provide a catalyst to develop strategies for improving oral feeding outcome for infants requiring prolonged respiratory support in the NICU.
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Affiliation(s)
- Emily Anderson
- School of Medicine, AU/UGA Medical Partnership, Augusta University Medical College of Georgia, Athens, Georgia, USA
| | - Mathew J Gregoski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Daniel Gehle
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - William T Head
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kris Thomas Hardy
- Department of Pediatrics (Neonatology), Medical University of South Carolina Children's Hospital, Charleston, South Carolina, USA
| | - Alison Chapman
- Department of Pediatrics (Neonatology), Medical University of South Carolina Children's Hospital, Charleston, South Carolina, USA
| | - Rita M Ryan
- Department of Pediatrics (Neonatology), Medical University of South Carolina Children's Hospital, Charleston, South Carolina, USA.,Department of Pediatrics (Neonatology), Case Western Reserve University, Rainbow Babies & Children's Hospital, Cleveland, Ohio, USA
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14
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Abstract
Bronchopulmonary dysplasia (BPD) is a chronic lung disease most commonly seen in preterm infants of low birthweight who required postnatal respiratory support. Although overall incidence rates have not changed, recent advancements in medical care have resulted in lower mortality rates, and those affected are beginning to live longer. As a result, the long-term repercussions of BPD are becoming more apparent. Whereas BPD has been thought of as a disease of just the lungs, resulting in abnormalities such as increased susceptibility to pulmonary infections, impaired exercise tolerance, and pulmonary hypertension, the enduring complications of BPD have been found to extend much further. This includes an increased risk for cerebral palsy and developmental delays, lower intelligence quotient (IQ) scores, impaired executive functioning, behavioral challenges, delays in expressive and receptive language development, and an increased risk of growth failure. In addition, the deficits of BPD have been found to influence much more than just physical health; BPD survivors have been noted to have higher rates of health care use, starting with the initial hospitalization and continuing with therapy and specialist follow-up, as well as impairments in quality of life, both physical and psychological, that continue into adulthood. The long-term consequences of BPD may best be addressed through future research, including better understanding of the pathophysiologic mechanisms leading to BPD, further comparisons between newborns with BPD and those without, and long-term assessment and management of BPD patients as adults.
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Affiliation(s)
- Travis D Homan
- Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Ravi P Nayak
- Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, Missouri.
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15
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Alain C, Samson N, Nadeau C, Beaudoin JF, Lienhart C, Counil C, Praud JP. Nasal respiratory support and tachypnea and oral feeding in full-term newborn lambs. J Appl Physiol (1985) 2021; 130:1436-1447. [PMID: 33661723 DOI: 10.1152/japplphysiol.00567.2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Newborn infants with respiratory difficulties frequently require nasal respiratory support such as nasal continuous positive airway pressure (nCPAP) or high-flow nasal cannulae (HFNC). Oral feeding of these infants under nasal respiratory support remains controversial out of fear of aspiration and cardiorespiratory events. The main objective of this study was to evaluate the safety of oral feeding under different types of nasal respiratory support in newborn lambs without or with tachypnea. Eight lambs aged 4-5 days were instrumented to record sucking, swallowing, respiration, ECG, oxygen saturation, and arterial blood gases. Each lamb was given two bottles of 30 mL of milk with a pause of 30 s under videofluoroscopy in four conditions [no respiratory support, nCPAP 6 cmH2O, HFNC 7 L/min, HFNCCPAP (= HFNC 7 L/min + CPAP 6 cmH2O)] administered in random order. The study was conducted in random order over 2 days, with or without standardized tachypnea induced by thoracic compression with a blood pressure cuff. Generalized linear mixed models were used to compare the four nasal respiratory supports in terms of safety (cardiorespiratory events and aspiration), sucking-swallowing-breathing coordination, and efficacy of oral feeding. Results reveal that no nasal respiratory support impaired the safety of oral feeding. Most of the few laryngeal penetrations we observed occurred with HFNCCPAP. Nasal CPAP modified sucking-swallowing-breathing coordination, whereas the efficiency of oral feeding decreased under HFNCCPAP. Results were similar with or without tachypnea. In conclusion, oral feeding under nasal respiratory support is generally safe in a term lamb, even with tachypnea.NEW & NOTEWORTHY The practice of orally feeding newborns suffering from respiratory problems while on nCPAP or HFNC remains controversial for fear of triggering cardiorespiratory events or aspiration pneumonia, or aggravating chronic lung disease. The present results show that bottle-feeding is generally safe in full-term lambs under nasal respiratory support, both without and with tachypnea.
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Affiliation(s)
- Charles Alain
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Nathalie Samson
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Charlène Nadeau
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Jean-François Beaudoin
- Centre d'imagerie moléculaire de Sherbrooke (CIMS), Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Camille Lienhart
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Clément Counil
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Jean-Paul Praud
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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16
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Sullivan BA, Slevin CC, Ahmad SM, Sinkin RA, Fairchild KD. Achievement of maturational milestones among very low birth weight infants. J Neonatal Perinatal Med 2021; 15:155-163. [PMID: 33967061 DOI: 10.3233/npm-200698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Very low birth weight (VLBW) infants must achieve several maturational milestones to be discharged home from the NICU. OBJECTIVE Describe the timing of maturational milestones in VLBW infants and the impact of clinical variables and milestone achievement on postmenstrual age (PMA) at discharge. METHODS For VLBW infants without severe lung disease discharged home from a level IV NICU, we assessed PMA at the achievement of thermoregulation, cardiorespiratory stability, feeding, and discharge. RESULTS In 400 infants (median GA 28.4 weeks), lower birth weight, white race, and having multiple comorbidities of prematurity predicted later discharge PMA. The most common milestone sequence was CPAP discontinuation, caffeine discontinuation, thermoregulation, apnea resolution, and full oral feeds. PMA at apnea resolution and full oral feeds correlated highly with discharge PMA. CONCLUSIONS In a single-center VLBW cohort, comorbidities of prematurity impacted the timing of NICU discharge through delay in oral feeding and cardiorespiratory stability.
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Affiliation(s)
- B A Sullivan
- Department of Pediatrics, Division of Neonatology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - C C Slevin
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - S M Ahmad
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - R A Sinkin
- Department of Pediatrics, Division of Neonatology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - K D Fairchild
- Department of Pediatrics, Division of Neonatology, University of Virginia School of Medicine, Charlottesville, VA, USA
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17
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Abstract
Congenital heart disease (CHD) is the most common birth defect for infants born in the United States, with approximately 36,000 affected infants born annually. While mortality rates for children with CHD have significantly declined, there is a growing population of individuals with CHD living into adulthood prompting the need to optimise long-term development and quality of life. For infants with CHD, pre- and post-surgery, there is an increased risk of developmental challenges and feeding difficulties. Feeding challenges carry profound implications for the quality of life for individuals with CHD and their families as they impact short- and long-term neurodevelopment related to growth and nutrition, sensory regulation, and social-emotional bonding with parents and other caregivers. Oral feeding challenges in children with CHD are often the result of medical complications, delayed transition to oral feeding, reduced stamina, oral feeding refusal, developmental delay, and consequences of the overwhelming intensive care unit (ICU) environment. This article aims to characterise the disruptions in feeding development for infants with CHD and describe neurodevelopmental factors that may contribute to short- and long-term oral feeding difficulties.
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18
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NICU infants who require a feeding gastrostomy for discharge. J Pediatr Surg 2021; 56:449-453. [PMID: 32828544 DOI: 10.1016/j.jpedsurg.2020.07.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 07/05/2020] [Accepted: 07/18/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To determine population data for infants receiving a gastrostomy tube (GT) in our Neonatal Intensive Care Unit (NICU) to better understand the premature infant population at risk for GT prior to discharge. STUDY DESIGN We identified all NICU infants born 2015-2016 who received a GT and determined the birth gestational age below which GTs were placed due to oral feeding failure secondary to prematurity-related comorbidities, rather than anomalies or other reasons. Aggregate data were used to compare infants born <30 weeks (w) gestation who received a GT with those who did not. RESULTS GTs were placed in 117 infants. More than half of the NICU patients who receive GTs were actually >32 weeks gestation; a cut-off of <30w was a good identifier for those who failed achieving full oral feeds due to prematurity-related problems. Infants born <30w (n = 282) not receiving GTs were discharged at a significantly lower postmenstrual age (36w) and lower weight (2.3 kg) compared with infants who received a GT (49w, 5 kg). CONCLUSIONS The population of premature infants born <30w gestation constitute the population of infants at risk for a GT based solely on prematurity. LEVELS OF EVIDENCE III.
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19
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Discontinuing Nasal Continuous Positive Airway Pressure in Infants ≤32 Weeks of Gestational Age: A Randomized Control Trial. J Pediatr 2021; 230:93-99.e3. [PMID: 33127365 DOI: 10.1016/j.jpeds.2020.10.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/16/2020] [Accepted: 10/21/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To compare immediate cessation of nasal continuous positive airway pressure (NCPAP) vs a stepwise decrease in pressure on the duration of NCPAP therapy in infants born prematurely. STUDY DESIGN A single center study in infants 230-326 weeks of gestational age. NCPAP was stopped either at 5 cm H2O (control) or 3 cm H2O after a stepwise pressure wean (wean) using defined stability and failure criteria. Primary outcome is total NCPAP days. RESULTS We enrolled 226 infants; 116 were randomly assigned to control and 110 to the wean group. There was no difference in the total NCPAP days between groups (median [25th, 75th percentiles] 16 [5, 36] vs 14 [7, 33] respectively). There were no differences between groups in secondary outcomes, including duration of hospital stay, critical care days, and oxygen supplementation. A higher proportion of control infants failed the initial attempt to discontinue NCPAP (43% vs 27%, respectively; P < .01) and required ≥2 attempts (20% vs 5%, respectively; P < .01). In addition, infants 23-27 weeks of gestational age in the wean group were 2.4-times more likely to successfully stop NCPAP at the first attempt (P = .02) vs controls. CONCLUSIONS Discontinuation of NCPAP after a gradual pressure wean to 3 cm H2O did not decrease the duration of NCPAP therapy compared with stopping from 5 cm H2O in infants ≤32 weeks of gestational age. However, weaning decreased failed initial attempts to stop NCPAP, particularly among infants <28 weeks of gestational age. TRIAL REGISTRATION Clinicaltrials.gov: NCT02064712.
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20
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Canning A, Clarke S, Thorning S, Chauhan M, Weir KA. Oral feeding for infants and children receiving nasal continuous positive airway pressure and high flow nasal cannula: a systematic review. BMC Pediatr 2021; 21:83. [PMID: 33596866 PMCID: PMC7887825 DOI: 10.1186/s12887-021-02531-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 01/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this systematic review was to determine whether introduction of oral feeding for infants and children receiving nasal continuous positive airway pressure (nCPAP) or high flow nasal cannula (HFNC) respiratory support facilitates achievement of full oral feeding without adverse effects, compared to no oral feeding (NPO; nil per oral) on CPAP or HFNC. METHODS A protocol was lodged with the PROSPERO International Prospective Register of Systematic Reviews. We searched Medline, Embase, CINAHL, CENTRAL and AustHealth from database inception to 10th June 2020. Study population included children (preterm to < 18 years) on nCPAP or HFNC who were orally feeding. Primary outcomes included full or partial oral feeding and oropharyngeal aspiration. Secondary outcomes examined adverse events including clinical signs of aspiration, aspiration pneumonia and deterioration in respiratory status. RESULTS The search retrieved 1684 studies following duplicate removal. Title and abstract screening identified 70 studies for full text screening and of these, 16 were included in the review for data extraction. Methods of non-invasive ventilation (NIV) included nCPAP (n = 6), nCPAP and HFNC (n = 5) and HFNC (n = 5). A metanalysis was not possible as respiratory modes and cohorts were not comparable. Eleven studies reported on adverse events. Oral feeding safety was predominantly based on retrospective data from chart entries and clinical signs, with only one study using an instrumental swallow evaluation (VFSS) to determine aspiration status. CONCLUSIONS Findings are insufficient to conclude whether commencing oral feeding whilst on nCPAP or HFNC facilitates transition to full oral feeding without adverse effects, including oropharyngeal aspiration. Further research is required to determine the safety and efficacy of oral feeding on CPAP and HFNC for infants and children. TRIAL REGISTRATION PROSPERO registration number: CRD42016039325 .
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Affiliation(s)
- Angie Canning
- Speech Pathology, Gold Coast University Hospital, Gold Coast Health, Gold Coast, Australia.
| | - Sally Clarke
- Queensland Children's Hospital, Children's Health Queensland, Brisbane, Australia
| | - Sarah Thorning
- Library Services, Gold Coast University Hospital, Gold Coast Health, Gold Cost, Australia
| | - Manbir Chauhan
- Newborn Care Unit, Gold Coast University Hospital, Gold Coast Health, Gold Coast, Australia
| | - Kelly A Weir
- Allied Health Sciences & Menzies Health Institute Queensland Griffith University, Gold Coast, Australia.,Allied Health Research Gold Coast Health, Gold Coast, Australia
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21
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Gibbs K, Jensen EA, Alexiou S, Munson D, Zhang H. Ventilation Strategies in Severe Bronchopulmonary Dysplasia. Neoreviews 2021; 21:e226-e237. [PMID: 32238485 DOI: 10.1542/neo.21-4-e226] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Bronchopulmonary dysplasia (BPD) is an acquired, developmental chronic lung disease that is a consequence of premature birth. In the most severe form of the disease, infants may require prolonged periods of positive pressure ventilation. BPD is a heterogeneous disease with lung mechanics that differ from those in respiratory distress syndrome; strategies to manage the respiratory support in infants with severe BPD should take this into consideration. When caring for these infants, practitioners need to shift from the acute care ventilation strategies that use frequent blood gases and support adjustments designed to minimize exposure to positive pressure. Infants with severe BPD benefit from a chronic care model that uses less frequent ventilator adjustments and provides the level of positive support that will achieve the longer-term goal of ongoing lung growth and repair.
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Affiliation(s)
| | | | - Stamatia Alexiou
- Pulmonology, Department of Pediatrics, Children's Hospital of Philadelphia and The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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22
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Bakker L, Jackson B, Miles A. Oral-feeding guidelines for preterm neonates in the NICU: a scoping review. J Perinatol 2021; 41:140-149. [PMID: 33288867 DOI: 10.1038/s41372-020-00887-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 10/14/2020] [Accepted: 11/20/2020] [Indexed: 01/02/2023]
Abstract
OBJECTIVE This scoping review describes the nature and evidence base of internationally available guidelines for the introduction of oral feeding for preterm infants in neonatal units. STUDY DESIGN Thirty-nine current infant oral feeding introduction guidelines were obtained, and their recommendations contrasted with available scientific literature. RESULT Documents were primarily from the USA, UK, Canada, and Australia, from hospitals, regional health authorities, and journal articles. Specifics of nonnutritive sucking, gestational age at first feed, exclusions to oral feeding, suggested interventions, and the definition of full oral feeding varied between documents. There was variable use of scientific evidence to back up recommendations. CONCLUSION Guidelines for oral feeding, whether written by clinicians or researchers, vary greatly in their recommendations and details of interventions. Areas more widely researched were more commonly discussed. Recommendations varied more when evidence was not available or weak. Guideline developers need to synthesize evidence and local variability to create appropriate guidelines.
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Affiliation(s)
- Lise Bakker
- The University of Auckland, Auckland, New Zealand.
| | | | - Anna Miles
- The University of Auckland, Auckland, New Zealand
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23
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Allen K, Galek K. The Influence of Airflow Via High-Flow Nasal Cannula on Duration of Laryngeal Vestibule Closure. Dysphagia 2020; 36:729-735. [PMID: 33006075 PMCID: PMC7529319 DOI: 10.1007/s00455-020-10193-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 09/21/2020] [Indexed: 11/29/2022]
Abstract
The purpose of this experimental study was to investigate the influence of airflow via high-flow nasal cannula (HFNC) on the duration of laryngeal vestibule closure (dLVC) and Penetration-Aspiration Scale (PAS) scores. Twenty-nine healthy adults participated in a repeated-measures design. Each participant completed a videofluoroscopic swallow study while receiving airflow via HFNC across a control condition of zero flow and conditions of 10, 20, 30, 40, 50, and 60 L/min. Five raters rated dLVC and PAS scores. Laryngeal vestibule closure was complete on all swallows. Linear regression revealed that the amount of airflow via HFNC significantly influenced dLVC, F(1, 810) = 19.056, p < .001. The mode of airway invasion for each airflow condition was PAS 2, with > 80% frequency compared to other PAS scores. Aspiration (PAS 7 or 8) did not occur. A Fisher's Exact test determined there was no association between normal/abnormal PAS score and no airflow/HFNC (p = .610). Findings indicate that for healthy adults, airflow via HFNC influenced dLVC in a dose-dependent manner with no change in airway invasion. The influence of HFNC on dLVC was a positive relationship, meaning when airflow increased, dLVC increased, and when airflow decreased, dLVC decreased. Modulation of dLVC in response to the amount of airflow highlights the ability of healthy adults to adapt to swallow conditions as needed to protect the airway.
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Affiliation(s)
- Katie Allen
- University of Nevada, 1664 North Virginia Street, Mailstop 0152, Reno, NV, 89557, USA.
| | - Kristine Galek
- University of Nevada, 1664 North Virginia Street, Mailstop 0152, Reno, NV, 89557, USA
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24
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Abstract
In the United States, preterm birth rates have steadily increased since 2014. Despite the recent advances in neonatal-perinatal care, more than 40% of very low-birth-weight infants develop chronic lung disease (CLD) and almost 25% have feeding difficulties resulting in delayed achievement of full oral feeds and longer hospital stay. Establishment of full oral feeds, a major challenge for preterm infants, becomes magnified among those on respiratory support and/or with CLD. The strategies to minimize aerodigestive disorders include supporting nonnutritive sucking, developing infant-directed feeding protocols, sensory oromotor stimulation, and early introduction of oral feeds.
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25
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Leibel SL, Castro M, McBride T, Hassall K, Sarmiento K, Ye XY, Shah V. Comparison of Continuous positive airway pressure versus High flow nasal cannula for Oral feeding Preterm infants (CHOmP): randomized pilot study. J Matern Fetal Neonatal Med 2020; 35:951-957. [PMID: 32138561 DOI: 10.1080/14767058.2020.1735339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: To assess the feasibility of conducting a study comparing nasal continuous positive airway pressure (nCPAP) or heated, humidified, high flow nasal cannula (HHHFNC) on oral feeding in preterm infants.Study design: Randomized controlled pilot study in a level III NICU, of infants' born ≤28°/7 weeks who at 34°/7 weeks post menstrual age (PMA) were dependent on noninvasive ventilation (NIV). Infants were randomized evenly to nCPAP or HHHFNC groups and orally fed on low-flow oxygen. The primary outcomes of enrollment and retention were assessed.Results: We enrolled 40 infants and 12 completed the study in the nCPAP group versus 13 in the HHHFNC group. Using our respiratory and feeding protocols, we showed overall enrollment and retention rates (95%CI) at 0.66 (0.54, 0.77) and 0.63 (0.48, 0.78), respectively. Breastfeeding rates were 82% in the nCPAP group and 76% in the HHHFNC group. Infants in the HHHFNC group reached full feeds 7 days earlier than those in the nCPAP groupConclusions: Based on our retention rate, an adequately powered randomized controlled trial can be performed to confirm or refute that HHHFNC is associated with achieving oral feeds earlier.Trial registration: United States National Library of Medicine (www.clinicaltrials.gov) Identifier: NCT02055339. First posted 2/5/2014.
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Affiliation(s)
- Sandra L Leibel
- Division of Neonatology, Department of Pediatrics, Rady Children's Hospital, University of California, San Diego, San Diego, CA, USA
| | - Marina Castro
- Division of Neonatology, Department of Paediatrics, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada.,Department of Pediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Tammy McBride
- Department of Pediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Kelly Hassall
- Department of Respiratory Therapy, St. Joseph's Healthcare, Hamilton, Canada
| | - Karla Sarmiento
- Department of Pediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Xiang Y Ye
- Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, Canada
| | - Vibhuti Shah
- Department of Pediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Canada.,Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, Canada
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26
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The effects of oral feeding while on nasal continuous positive airway pressure (NCPAP) in preterm infants. J Perinatol 2020; 40:909-915. [PMID: 32086439 PMCID: PMC7224016 DOI: 10.1038/s41372-020-0632-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 01/30/2020] [Accepted: 02/11/2020] [Indexed: 11/09/2022]
Abstract
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.
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27
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Impact of High Flow Nasal Cannula Therapy on Oral Feeding in Very Low Birth Weight Infants with Chronic Lung Disease. J UOEH 2019; 41:131-138. [PMID: 31292356 DOI: 10.7888/juoeh.41.131] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Previous studies on high-flow nasal cannula (HFNC) in very-low-birth-weight infants (VLBWIs) focused on comparing HFNC with nasal continuous positive airway pressure (nCPAP) to determine the usefulness of HFNC as a backup in the case of extubation failure and nasal trauma; however, the studies did not consider oral feeding. This retrospective case-control study aimed at elucidating whether HFNC could prevent the delay in feeding and achievement of full oral feeding in VLBWIs with chronic lung disease (CLD). Forty five VLBWIs were enrolled in this study: an HFNC group (n = 11) that was supported by HFNC at oral feeding initiation, and a non-HFNC group (n = 34) that could start oral feeding without HFNC. The gestational age and birth weight of the HFNC group were lower than those in the non-HFNC group. The median duration of exposure to oxygen and neonatal intensive care unit stay were comparable in both groups. The timings of oral feeding initiation and full oral feeding achievement in both groups were not significantly different: 35.3 (33.0 - 38.1) vs. 35.5 (33.7 - 42.4) weeks (P = 0.91) for the HFNC and 38.6 (34.4 - 42.3) vs. 36.7 (34.6 - 44.4) weeks postmenstrual age (P = 0.29) for the non-HFNC. Clinically significant aspiration pneumonia during the period of oral feeding was not observed in the HFNC group. Respiratory support by HFNC in VLBWIs with CLD might prevent oral feeding delay. Initiation of oral feeding of VLBWIs on HFNC might be safe and might accelerate the achievement of oral feeding milestones.
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LaTuga MS, Mittelstaedt G, Moon JY, Kim M, Murray-Keane L, Si W, Havranek T. Clinical characteristics of premature infants who orally feed on continuous positive airway pressure. Early Hum Dev 2019; 139:104833. [PMID: 31476544 DOI: 10.1016/j.earlhumdev.2019.104833] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 06/05/2019] [Accepted: 08/12/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Between 32 and 34 weeks postconceptional age (PCA), premature infants typically achieve neuromuscular maturation to initiate the coordination of a nutritive suck triad. Many premature infants also require intubation, which has been associated with dysphagia in adults and infants. At our institution, despite these factors, some infants have been noted to tolerate oral feeds while on continuous positive airway pressure (CPAP). AIMS Compare the clinical characteristics and duration of intubation in infants that initiate oral feedings on CPAP to infants that did not begin oral feeding on CPAP. STUDY DESIGN Retrospective case control study. SUBJECTS Infants with gestational age < 32 weeks who required CPAP at 32 weeks PCA. OUTCOME MEASURES Oral feeding was defined as any oral feed ≥5 ml. Duration of intubation was defined as the number of intubated days prior to 32 weeks PCA. RESULTS Of the 243 infants on CPAP at 32 weeks PCA, 31% (n = 76) began oral feeding on CPAP. Infants who initiated oral feeding on CPAP were of younger gestational age at birth (median 26 versus 27 weeks, p < 0.001) and remained intubated for longer (median 10.5 versus 2 days, p < 0.001). CONCLUSIONS Infants who began oral feeding on CPAP had lower gestational age and longer duration of intubation than infants who started oral feeding off CPAP.
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Affiliation(s)
- Mariam Susan LaTuga
- Department of Pediatrics, Albert Einstein College of Medicine, United States of America.
| | - Gina Mittelstaedt
- Department of Pediatrics, Albert Einstein College of Medicine, United States of America
| | - Jee-Young Moon
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, United States of America
| | - Mimi Kim
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, United States of America
| | - Lindsay Murray-Keane
- Department of Rehabilitation Medicine, Albert Einstein College of Medicine, United States of America
| | - Wendy Si
- Department of Pediatrics, Albert Einstein College of Medicine, United States of America
| | - Thomas Havranek
- Department of Pediatrics, Albert Einstein College of Medicine, United States of America
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Bapat R, Gulati IK, Jadcherla S. Impact of SIMPLE Feeding Quality Improvement Strategies on Aerodigestive Milestones and Feeding Outcomes in BPD Infants. Hosp Pediatr 2019; 9:859-866. [PMID: 31658999 DOI: 10.1542/hpeds.2018-0243] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
BACKGROUND AND OBJECTIVES Delays with enteral and oral feeding milestones among premature infants with bronchopulmonary dysplasia (BPD) can be due to provider variation or infant-dependent factors. Our objectives with this study were to compare aerodigestive milestones and length of stay in BPD infants after implementing a quality improvement program to improve feeding outcomes. METHODS Using the Institute for Healthcare Improvement model for quality improvement, we implemented the simplified, individualized, milestone-targeted, pragmatic, longitudinal, and educational (SIMPLE) feeding strategy to enhance feeding and aerodigestive milestones among BPD infants. The key interventions addressed were as follows: (1) enteral feed initiation and advancement protocol; (2) oral feeding progression guidelines, optimization of respiratory support, feeding readiness scores, nonnutritive breastfeeding, and cue-based feeding; (3) active multidisciplinary collaboration; and (4) family-centered care. Comparisons were made between baseline (January 2009 to March 2010) and SIMPLE feeding strategy (May 2010 to December 2013) groups. Both groups included infants between 23 0/7 and 32 6/7 weeks' birth gestation, and ≤34 weeks' postmenstrual age at admission and discharge. RESULTS The baseline group and SIMPLE feeding group included 92 patients and 187 patients, respectively. Full enteral feeding, first oral feeding, full oral feeding, and length of stay milestones were (all P < .05) achieved sooner in the SIMPLE feeding group. Although the overall prevalence of BPD in the 2 groups is similar, the incidence of moderate BPD has decreased (P < .05) and severe BPD has increased (P < .05) in the SIMPLE feeding group. CONCLUSIONS SIMPLE feeding strategy advances postnatal maturation and acquisition of feeding milestones irrespective of the severity of BPD and impacts the length of stay, thereby lowering resource use.
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Affiliation(s)
- Roopali Bapat
- Nationwide Children's Hospital, Columbus, Ohio; and
- Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Ish K Gulati
- Nationwide Children's Hospital, Columbus, Ohio; and
- Innovative Feeding Disorders Program, The Research Institute at Nationwide Children's Hospital
- Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Sudarshan Jadcherla
- Nationwide Children's Hospital, Columbus, Ohio; and
- Innovative Feeding Disorders Program, The Research Institute at Nationwide Children's Hospital
- Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio
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McCollum ED, Mvalo T, Eckerle M, Smith AG, Kondowe D, Makonokaya D, Vaidya D, Billioux V, Chalira A, Lufesi N, Mofolo I, Hosseinipour M. Bubble continuous positive airway pressure for children with high-risk conditions and severe pneumonia in Malawi: an open label, randomised, controlled trial. THE LANCET RESPIRATORY MEDICINE 2019; 7:964-974. [PMID: 31562059 PMCID: PMC6838668 DOI: 10.1016/s2213-2600(19)30243-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/08/2019] [Accepted: 07/09/2019] [Indexed: 12/14/2022]
Abstract
Background Pneumonia is the leading cause of death among children globally. Most pneumonia deaths in low-income and middle-income countries (LMICs) occur among children with HIV infection or exposure, severe malnutrition, or hypoxaemia despite antibiotics and oxygen. Non-invasive bubble continuous positive airway pressure (bCPAP) is considered a safe ventilation modality that might improve child pneumonia survival. bCPAP outcomes for high-risk African children with severe pneumonia are unknown. Since most child pneumonia hospitalisations in Africa occur in non-tertiary district hospitals without daily physician oversight, we aimed to examine whether bCPAP improves severe pneumonia mortality in such settings. Methods This open-label, randomised, controlled trial was done in the general paediatric ward of Salima District Hospital, Malawi. We enrolled children aged 1–59 months old with WHO-defined severe pneumonia and either HIV infection or exposure, severe malnutrition, or an oxygen saturation of less than 90%. Children were randomly assigned 1:1 to low-flow nasal cannula oxygen or nasal bCPAP. Non-physicians administered care; the primary outcome was hospital survival. Primary analyses were by intention-to-treat and interim and adverse events analyses per protocol. This trial is registered with ClinicalTrials.gov, number NCT02484183, and is closed. Findings We screened 1712 children for eligibility between June 23, 2015, and March 21, 2018. The data safety and monitoring board stopped the trial for futility after 644 of the intended 900 participants were enrolled. 323 children were randomly assigned to oxygen and 321 to bCPAP. 35 (11%) of 323 children who received oxygen died in hospital, as did 53 (17%) of 321 who received bCPAP (relative risk 1·52; 95% CI 1·02–2·27; p=0·036). 13 oxygen and 17 bCPAP patients lacked hospital outcomes and were considered lost to follow-up. Suspected adverse events related to treatment occurred in 11 (3%) of 321 children receiving bCPAP and 1 (<1%) of 323 children receiving oxygen. Four bCPAP and one oxygen group deaths were classified as probable aspiration episodes, one bCPAP death as probable pneumothorax, and six non-death bCPAP events included skin breakdown around the nares. Interpretation bCPAP treatment in a paediatric ward without daily physician supervision did not reduce hospital mortality among high-risk Malawian children with severe pneumonia, compared with oxygen. The use of bCPAP within certain patient populations and non-intensive care settings might carry risk that was not previously recognised. bCPAP in LMICs needs further evaluation before wider implementation for child pneumonia care. Funding Bill & Melinda Gates Foundation, International AIDS Society, Health Empowering Humanity.
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Affiliation(s)
- Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Tisungane Mvalo
- University of North Carolina Project Malawi, Lilongwe, Malawi; Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, NC, USA
| | - Michelle Eckerle
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew G Smith
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Davie Kondowe
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Don Makonokaya
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | | | | | | | | | - Innocent Mofolo
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Mina Hosseinipour
- University of North Carolina Project Malawi, Lilongwe, Malawi; Division of Infectious Disease, University of North Carolina at Chapel Hill, NC, USA
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Canning A, Fairhurst R, Chauhan M, Weir KA. Oral Feeding for Infants and Children Receiving Nasal Continuous Positive Airway Pressure and High-Flow Nasal Cannula Respiratory Supports: A Survey of Practice. Dysphagia 2019; 35:443-454. [DOI: 10.1007/s00455-019-10047-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 07/09/2019] [Accepted: 08/05/2019] [Indexed: 12/19/2022]
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Positive Airway Pressure Versus High-Flow Nasal Cannula for Prevention of Extubation Failure in Infants After Congenital Heart Surgery. Pediatr Crit Care Med 2019; 20:149-157. [PMID: 30407954 DOI: 10.1097/pcc.0000000000001783] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Compare the impact of initial extubation to positive airway pressure versus high-flow nasal cannula on postoperative outcomes in neonates and infants after congenital heart surgery. DESIGN Retrospective cohort study with propensity-matched analysis. SETTING Cardiac ICU within a tertiary care children's hospital. PATIENTS Patients less than 6 months old initially extubated to either high-flow nasal cannula or positive airway pressure after cardiac surgery with cardiopulmonary bypass were included (July 2012 to December 2015). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 258 encounters, propensity matching identified 49 pairings of patients extubated to high-flow nasal cannula versus positive airway pressure. Extubation failure was 12% for all screened encounters. After matching, there was no difference in extubation failure rate between groups (positive airway pressure 16% vs high-flow nasal cannula 10%; p = 0.549). However, compared with high-flow nasal cannula, patients initially extubated to positive airway pressure experienced greater resource utilization: longer time to low-flow nasal cannula (83 vs 28 hr; p = 0.006); longer time to room air (159 vs 110 hr; p = 0.013); and longer postsurgical hospital length of stay (22 vs 14 d; p = 0.015). CONCLUSIONS In this pediatric cohort, primary extubation to positive airway pressure was not superior to high-flow nasal cannula with respect to prevention of extubation failure after congenital heart surgery. Compared with high-flow nasal cannula, use of positive airway pressure was associated with increased hospital resource utilization. Prospective initiatives aimed at establishing best clinical practice for postoperative noninvasive respiratory support are needed.
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Al-Lawama M, Alkhatib H, Wakileh Z, Elqaisi R, AlMassad G, Badran E, Hartman T. Bubble CPAP therapy for neonatal respiratory distress in level III neonatal unit in Amman, Jordan: a prospective observational study. Int J Gen Med 2018; 12:25-30. [PMID: 30636889 PMCID: PMC6307683 DOI: 10.2147/ijgm.s185264] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Bubble continuous positive airway pressure (bCPAP), a noninvasive respiratory support modality used to manage newborns with respiratory distress, provides continuous pressure that helps prevent derecruitment of alveoli, increasing the lungs' functional residual capacity, and thus decreasing the work of breathing. bCPAP can be used to manage various respiratory conditions in the newborn. In this prospective study, we describe our experience using bCPAP therapy as the primary respiratory support in a level III neonatal unit in Amman, Jordan. In addition to reporting therapeutic indications, durations, and side effects, we aimed to identify areas requiring improvement in bCPAP therapy in our population. PATIENTS AND METHODS This prospective observational study investigated the usage of bCPAP in the management of respiratory distress in newborns admitted to a Jordan University Hospital in Amman. The newborns were followed until discharge. The patients' demographic and clinical data were recorded. RESULTS A total of 143 babies (mean gestational age, 36±2.7 weeks; mean birth weight, 2,770±1,800 g) were included. All received bCPAP as the primary respiratory support. The most common underlying cause of respiratory distress was transient tachypnea of the newborn (42%), followed by prolonged respiratory transition (34%). The therapy success rate was 93.7%; only nine infants failed bCPAP. The most common side effect was physical facial injury. CONCLUSION The use of neonatal bCPAP therapy is well established in Jordan University Hospital. The area of potential improvement was the low rate of bCPAP use as a primary respiratory support in extremely premature infants.
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Affiliation(s)
- Manar Al-Lawama
- Pediatric Department, School of Medicine, Jordan University Hospital, The University of Jordan, Queen Rania Street, Amman 11942, Jordan,
| | - Haitham Alkhatib
- Pediatric Department, School of Medicine, Jordan University Hospital, The University of Jordan, Queen Rania Street, Amman 11942, Jordan,
| | - Zaid Wakileh
- Pediatric Department, School of Medicine, Jordan University Hospital, The University of Jordan, Queen Rania Street, Amman 11942, Jordan,
| | - Randa Elqaisi
- Pediatric Department, School of Medicine, Jordan University Hospital, The University of Jordan, Queen Rania Street, Amman 11942, Jordan,
| | - Ghada AlMassad
- Pediatric Department, School of Medicine, Jordan University Hospital, The University of Jordan, Queen Rania Street, Amman 11942, Jordan,
| | - Eman Badran
- Pediatric Department, School of Medicine, Jordan University Hospital, The University of Jordan, Queen Rania Street, Amman 11942, Jordan,
| | - Tyler Hartman
- Pediatric department, Geisel School of Medicine, Dartmouth University, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA
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Brumbaugh JE, Colaizy TT, Saha S, Van Meurs KP, Das A, Walsh MC, Bell EF. Oral feeding practices and discharge timing for moderately preterm infants. Early Hum Dev 2018; 120:46-52. [PMID: 29654994 PMCID: PMC5951763 DOI: 10.1016/j.earlhumdev.2018.04.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 03/24/2018] [Accepted: 04/02/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Oral feeding skills of moderately preterm infants are not mature at birth. AIMS To establish the relationship between postmenstrual age at introduction of first oral feeding and attainment of full oral feeding and hospital discharge for moderately preterm infants. STUDY DESIGN Multicenter retrospective analysis of a prospective cohort of moderately preterm infants admitted to a Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network hospital. SUBJECTS 6146 infants born at 29-33 weeks' gestation from January 2012 to November 2013. OUTCOME MEASURES Postmenstrual age at full oral feeding and at hospital discharge. RESULTS The median postmenstrual age at first oral feeding was 33.9 weeks (interquartile range 33.1-34.3). For each week earlier at first oral feeding, full oral feeding occurred 4.5 days earlier (p < 0.0001) and hospital stay was shortened by 3.4 days (p < 0.0001). Higher birth weight (p < 0.0001) and black maternal race (p = 0.0001) were associated with younger postmenstrual age at full oral feeding and at discharge. CONCLUSION Moderately preterm infants with earlier introduction of oral feeding achieved earlier full oral feeding and hospital discharge.
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Affiliation(s)
- Jane E. Brumbaugh
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Tarah T. Colaizy
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Shampa Saha
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, NC, USA
| | | | - Abhik Das
- Social, Statistical, and Environmental Sciences Unit, RTI International, Rockville, MD, USA
| | - Michele C. Walsh
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, USA
| | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
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Nasal continuous positive airway pressure influences bottle-feeding in preterm lambs. Pediatr Res 2017; 82:926-933. [PMID: 28700565 DOI: 10.1038/pr.2017.162] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 04/26/2017] [Indexed: 11/08/2022]
Abstract
BackgroundIn preterm infants, the time from initiation to full oral feeding can take weeks, which represents a very worrisome problem in neonatal medicine. Although current knowledge suggests that oral feeding should be introduced early, this is often delayed due to the need for prolonged nasal continuous positive airway pressure (nCPAP). Indeed, most caregivers fear that nCPAP could disrupt sucking-swallowing-breathing coordination and induce tracheal aspiration. The goal of the present study was to assess the impact of nCPAP delivered by the Infant Flow System on the physiology of sucking-swallowing-breathing coordination during bottle-feeding in preterm lambs over 24 h.MethodsSeventeen lambs (8 control, 9 nCPAP of 6 cmH2O) born 14 days prematurely were instrumented to record sucking, swallowing, respiration, ECG, and oxygenation. They were fed via a nasogastric tube for the first 5 days of life until introduction of bottle-feeding every 4 h for 24 h.ResultsnCPAP increased the feeding efficiency while maintaining higher oxygenation without any deleterious cardiorespiratory events. However, coughs were observed in lambs under nCPAP immediately following bottle-feeding and may be related to the high milk flow in preterm lambs.ConclusionFurther studies documenting tracheal aspirations are needed, especially in preterm lambs under nCPAP for moderate respiratory difficulties, to further inform future clinical studies.
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Jadcherla SR, Bhandari V. "Pressure" to feed the preterm newborn: associated with "positive" outcomes? Pediatr Res 2017; 82:899-900. [PMID: 28902187 PMCID: PMC5774015 DOI: 10.1038/pr.2017.198] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 08/01/2017] [Indexed: 12/03/2022]
Affiliation(s)
- Sudarshan R. Jadcherla
- Divisions of Neonatology, Pediatric Gastroenterology and Nutrition, Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Vineet Bhandari
- Section of Neonatology, Department of Pediatrics, St. Christopher’s Hospital for Children, Drexel University College of Medicine, Philadelphia, PA,Address for correspondence: Vineet Bhandari, MD, DM, Drexel University College of Medicine, St. Christopher’s Hospital for Children, 160 Erie Avenue, Philadelphia, PA 19134, Phone: 215-427-5202, Fax: 215-427-8192,
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37
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Glackin SJ, O'Sullivan A, George S, Semberova J, Miletin J. High flow nasal cannula versus NCPAP, duration to full oral feeds in preterm infants: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed 2017; 102:F329-F332. [PMID: 28011792 DOI: 10.1136/archdischild-2016-311388] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 09/24/2016] [Accepted: 11/29/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare the time taken by preterm infants with evolving chronic lung disease to achieve full oral feeding when supported with humidified high flow nasal cannula (HFNC) or nasal continuous positive airway pressure (NCPAP). DESIGN Single centre randomised controlled trial. SETTING Level III neonatal intensive care unit at the Coombe Women and Infants University Hospital, Dublin, Ireland. PATIENTS Very low birthweight (birth weight <1500 g) infants born before 30 weeks' gestation who were NCPAP-dependent at 32 weeks corrected gestational age were eligible to participate. INTERVENTIONS Enrolled infants were randomised in a 1:1 ratio to receive HFNC or NCPAP. Participants were monitored daily until full oral feeding was established and the baby was off respiratory support. MAIN OUTCOME MEASURES Our primary outcome was the number of days taken to establish full oral feeds (defined as oral intake ≥120 mL/kg/day) from the time of randomisation. We estimated that enrolling 44 subjects (22 in each group) would allow us demonstrate a 7-day difference in our primary outcome with 80% power and α of 5%. RESULTS Forty-four infants were randomised (22 to HFNC vs 22 to NCPAP). The mean time to achieve full oral feeding was not different between the groups (HFNC 36.5 (±18.2) days vs NCPAP 34.1 (±11.2) days, p=0.61). CONCLUSIONS Preterm infants treated with HFNC did not achieve full oral feeding more quickly than infants treated with NCPAP. TRIAL REGISTRATION NUMBER ISRCTN66716753.
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Affiliation(s)
- Sinead J Glackin
- Department of Neonatology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Anne O'Sullivan
- Department of Neonatology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Sherly George
- Department of Neonatology, Coombe Women and Infants University Hospital, Dublin, Ireland.,UCD School of Medicine, University College Dublin, Dublin, Ireland
| | - Jana Semberova
- Department of Neonatology, Coombe Women and Infants University Hospital, Dublin, Ireland.,Institute for the Care of Mother and Child, Prague, Czech Republic
| | - Jan Miletin
- Department of Neonatology, Coombe Women and Infants University Hospital, Dublin, Ireland.,UCD School of Medicine, University College Dublin, Dublin, Ireland.,Institute for the Care of Mother and Child, Prague, Czech Republic.,3rd Faculty of Medicine, Charles University, Prague, Czech Republic
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38
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Effect of nasal continuous positive airway pressure on the pharyngeal swallow in neonates. J Perinatol 2017; 37:398-403. [PMID: 28055023 DOI: 10.1038/jp.2016.229] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 10/18/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Feeding neonates orally while on nasal continuous positive airway pressure (nCPAP) is a common practice. We hypothesize that pressurized airflow provided by nCPAP will alter the swallowing mechanism in neonates, increasing the risk of aspiration during oral feeding. STUDY DESIGN Infants receiving nCPAP with a RAM cannula and tolerating at least 50% of their feeding orally were included in the study (one term; six preterm infants). Each participant underwent a videofluoroscopic swallow study while on nCPAP and off nCPAP. A non-parametric signed-rank test was used for paired data. RESULT The incidence of deep penetration (P=0.03) and aspiration (P=0.01) decreased significantly off-nCPAP compared with on-nCPAP. However, the incidence of mild penetration (P=0.65) and nasopharyngeal reflux (P=0.87) remained the same under both conditions. CONCLUSION Oral feeding while on-nCPAP significantly increases the risk of laryngeal penetration and tracheal aspiration events. We recommend caution when initiating oral feedings on nCPAP.
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Samson N, Nadeau C, Vincent L, Cantin D, Praud JP. Effects of Nasal Continuous Positive Airway Pressure and High-Flow Nasal Cannula on Sucking, Swallowing, and Breathing during Bottle-Feeding in Lambs. Front Pediatr 2017; 5:296. [PMID: 29387680 PMCID: PMC5776098 DOI: 10.3389/fped.2017.00296] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 12/21/2017] [Indexed: 12/02/2022] Open
Abstract
The use of prolonged respiratory support under the form of high-flow nasal cannula (HFNC) or nasal continuous positive airway pressure (nCPAP) is frequent in newborn infants. Introduction of oral feeding under such nasal respiratory support is, however, highly controversial among neonatologists, due to the fear that it could disrupt sucking, swallowing, and breathing coordination and in turn induce cardiorespiratory events. The recent observation of tracheal aspirations during bottle-feeding in preterm infants under nCPAP justifies the use of animal models to perform more comprehensive physiological studies on the subject, in order to gain further insights for clinical studies. The objective of this study was to assess and compare the impact of HFNC and nCPAP on bottle-feeding in newborn lambs, in terms of bottle-feeding efficiency and safety as well as sucking-swallowing-breathing coordination. Eight full-term lambs were instrumented to record sucking, swallowing, and respiration as well as electrocardiogram and oxygenation. Lambs were bottle-fed in a standardized manner during three randomly ordered conditions, namely nCPAP 6 cmH2O, HFNC 7 L/min, and no respiratory support. Results revealed that nCPAP decreased feeding duration [25 vs. 31 s (control) vs. 57 s (HFNC), p = 0.03] and increased the rate of milk transfer [2.4 vs. 1.9 mL/s (control) vs.1.1 mL/s (HFNC), p = 0.03]. No other indices of bottle-feeding safety or sucking-swallowing-breathing coordination were significantly altered by HFNC or nCPAP. In conclusion, our results obtained in full-term newborn lambs suggest that: (i) nCPAP 6 cmH2O, but not HFNC 7 L/min, increases bottle-feeding efficiency; (ii) bottle-feeding is safe under nCPAP 6 cmH2O and HFNC 7 L/min, with no significant alteration in sucking-swallowing-breathing coordination. The present informative and reassuring data in full-term healthy lambs must be complemented by similar studies in preterm lambs, including mild-to-moderate respiratory distress alleviated by respiratory support in order to mimic preterm infants with bronchopulmonary dysplasia and pave the way for clinical studies.
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Affiliation(s)
- Nathalie Samson
- Neonatal Respiratory Research Unit, Department of Pediatrics, Université de Sherbrooke, Sherbrooke, QC, Canada.,Neonatal Respiratory Research Unit, Department of Pharmacology - Physiology, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Charlène Nadeau
- Neonatal Respiratory Research Unit, Department of Pediatrics, Université de Sherbrooke, Sherbrooke, QC, Canada.,Neonatal Respiratory Research Unit, Department of Pharmacology - Physiology, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Laurence Vincent
- Neonatal Respiratory Research Unit, Department of Pediatrics, Université de Sherbrooke, Sherbrooke, QC, Canada.,Neonatal Respiratory Research Unit, Department of Pharmacology - Physiology, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Danny Cantin
- Neonatal Respiratory Research Unit, Department of Pediatrics, Université de Sherbrooke, Sherbrooke, QC, Canada.,Neonatal Respiratory Research Unit, Department of Pharmacology - Physiology, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Jean-Paul Praud
- Neonatal Respiratory Research Unit, Department of Pediatrics, Université de Sherbrooke, Sherbrooke, QC, Canada.,Neonatal Respiratory Research Unit, Department of Pharmacology - Physiology, Université de Sherbrooke, Sherbrooke, QC, Canada
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Kashou NH, Dar IA, El-Mahdy MA, Pluto C, Smith M, Gulati IK, Lo W, Jadcherla SR. Brain Lesions among Orally Fed and Gastrostomy-Fed Dysphagic Preterm Infants: Can Routine Qualitative or Volumetric Quantitative Magnetic Resonance Imaging Predict Feeding Outcomes? Front Pediatr 2017; 5:73. [PMID: 28443270 PMCID: PMC5385332 DOI: 10.3389/fped.2017.00073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 03/24/2017] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The usefulness of qualitative or quantitative volumetric magnetic resonance imaging (MRI) in early detection of brain structural changes and prediction of adverse outcomes in neonatal illnesses warrants further investigation. Our aim was to correlate certain brain injuries and the brain volume of feeding-related cortical and subcortical regions with feeding method at discharge among preterm dysphagic infants. MATERIALS AND METHODS Using a retrospective observational study design, we examined MRI data among 43 (22 male; born at 31.5 ± 0.8 week gestation) infants who went home on oral feeding or gastrostomy feeding (G-tube). MRI scans were segmented, and volumes of brainstem, cerebellum, cerebrum, basal ganglia, thalamus, and vermis were quantified, and correlations were made with discharge feeding outcomes. Chi-squared tests were used to evaluate MRI findings vs. feeding outcomes. ANCOVA was performed on the regression model to measure the association of maturity and brain volume between groups. RESULTS Out of 43 infants, 44% were oral-fed and 56% were G-tube fed at hospital discharge (but not at time of the study). There was no relationship between qualitative brain lesions and feeding outcomes. Volumetric analysis revealed that cerebellum was greater (p < 0.05) in G-tube fed infants, whereas cerebrum volume was greater (p < 0.05) in oral-fed infants. Other brain regions did not show volumetric differences between groups. CONCLUSION This study concludes that neither qualitative nor quantitative volumetric MRI findings correlate with feeding outcomes. Understanding the complexity of swallowing and feeding difficulties in infants warrants a comprehensive and in-depth functional neurological assessment.
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Affiliation(s)
- Nasser H Kashou
- Wright State University, Image Analysis Lab, Dayton, OH, USA
| | - Irfaan A Dar
- Wright State University, Image Analysis Lab, Dayton, OH, USA.,Innovative Research Program in Neonatal and Infant Feeding Disorders, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Mohamed A El-Mahdy
- Innovative Research Program in Neonatal and Infant Feeding Disorders, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Charles Pluto
- Department of Radiology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Mark Smith
- Department of Radiology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ish K Gulati
- Innovative Research Program in Neonatal and Infant Feeding Disorders, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Division of Neonatology, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Warren Lo
- Department of Radiology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Sudarshan R Jadcherla
- Innovative Research Program in Neonatal and Infant Feeding Disorders, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Division of Neonatology, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
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Jadcherla SR, Hasenstab KA, Sitaram S, Clouse BJ, Slaughter JL, Shaker R. Effect of nasal noninvasive respiratory support methods on pharyngeal provocation-induced aerodigestive reflexes in infants. Am J Physiol Gastrointest Liver Physiol 2016; 310:G1006-14. [PMID: 27012774 PMCID: PMC4935482 DOI: 10.1152/ajpgi.00307.2015] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 03/22/2016] [Indexed: 01/31/2023]
Abstract
The pharynx is a locus of provocation among infants with aerodigestive morbidities manifesting as dysphagia, life-threatening events, aspiration-pneumonia, atelectasis, and reflux, and such infants often receive nasal respiratory support. We determined the impact of different oxygen delivery methods on pharyngeal stimulation-induced aerodigestive reflexes [room air (RA), nasal cannula (NC), and nasal continuous positive airway pressure (nCPAP)] while hypothesizing that the sensory motor characteristics of putative reflexes are distinct. Thirty eight infants (28.0 ± 0.7 wk gestation) underwent pharyngoesophageal manometry and respiratory inductance plethysmography to determine the effects of graded pharyngeal stimuli (n = 271) on upper and lower esophageal sphincters (UES, LES), swallowing, and deglutition-apnea. Comparisons were made between NC (n = 19), nCPAP (n = 9), and RA (n = 10) groups. Importantly, NC or nCPAP (vs. RA) had: 1) delayed feeding milestones (P < 0.05), 2) increased pharyngeal waveform recruitment and duration, greater UES nadir pressure, decreased esophageal contraction duration, decreased distal esophageal contraction amplitude, and decreased completely propagated esophageal peristalsis (all P < 0.05), and 3) similarly developed UES contractile and LES relaxation reflexes (P > 0.05). We conclude that aerodigestive reflexes were similarly developed in infants using noninvasive respiratory support with adequate upper and lower aerodigestive protection. Increased concern for GERD is unfounded in this population. These infants may benefit from targeted oromotor feeding therapies and safe pharyngeal bolus transit to accelerate feeding milestones.
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Affiliation(s)
- Sudarshan R. Jadcherla
- 1The Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research, Nationwide Children's Hospital Research Institute, Columbus Ohio; ,2The Neonatal Aerodigestive Pulmonary Program, Nationwide Children's Hospital, Columbus, Ohio; ,3Divisions of Neonatology, Department of Pediatrics; The Ohio State University College of Medicine, Columbus, Ohio; and
| | - Kathryn A. Hasenstab
- 1The Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research, Nationwide Children's Hospital Research Institute, Columbus Ohio; ,2The Neonatal Aerodigestive Pulmonary Program, Nationwide Children's Hospital, Columbus, Ohio;
| | - Swetha Sitaram
- 1The Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research, Nationwide Children's Hospital Research Institute, Columbus Ohio;
| | - Brian J. Clouse
- 2The Neonatal Aerodigestive Pulmonary Program, Nationwide Children's Hospital, Columbus, Ohio;
| | - Jonathan L. Slaughter
- 3Divisions of Neonatology, Department of Pediatrics; The Ohio State University College of Medicine, Columbus, Ohio; and
| | - Reza Shaker
- 4Gastroenterology and Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Sahni R, Schiaratura M, Polin RA. Strategies for the prevention of continuous positive airway pressure failure. Semin Fetal Neonatal Med 2016; 21:196-203. [PMID: 26936186 DOI: 10.1016/j.siny.2016.02.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Progress in neonatal intensive care is closely linked to improvements in the management of respiratory failure in preterm infants. Current modalities of respiratory support range from the more benign continuous positive airway pressure (CPAP) to various modes of mechanical ventilation. Data from recent randomized control trials suggest that the use of nasal (n)CPAP as the initial mode of respiratory support in critically ill very low birth weight infants is associated with a lower incidence of chronic lung disease. The practice of early initiation of nasal-prong CPAP in all spontaneously breathing infants at Columbia University has resulted in very low rates of chronic lung disease for decades. Many institutions have attempted to replicate the practices and results at Columbia University. However, success rates with nCPAP are highly variable, which may in part be attributable to how well it is utilized. With recent renewed interest in non-invasive respiratory support, particularly bubble nCPAP, it is essential to evaluate strategies for the prevention of CPAP failure. This review discusses strategies that address these issues and shares the practical aspects for replicating success with bubble nCPAP. In addition, it reviews desirable features, major components, and physiological consequences of various bubble CPAP systems along with clinical experience of CPAP use.
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Affiliation(s)
- Rakesh Sahni
- Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Maria Schiaratura
- NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Richard A Polin
- Columbia University College of Physicians and Surgeons, New York, NY, USA.
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Dalgleish SR, Kostecky LL, Blachly N. Eating in "SINC": Safe Individualized Nipple-Feeding Competence, a Quality Improvement Project to Explore Infant-Driven Oral Feeding for Very Premature Infants Requiring Noninvasive Respiratory Support. Neonatal Netw 2016; 35:217-227. [PMID: 27461200 DOI: 10.1891/0730-0832.35.4.217] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Oral feeding is a developmental task for all premature infants. often, independent nipple feeding is the last barrier to discharge home from the NICU. A relationship exists between consistent, infant-driven feeding management practices and improved feeding performance. Conversely, a random approach to feeding may contribute to poor short-term and long-term clinical outcomes. We report a quality improvement project that was undertaken across five NICUs in an urban setting. our aim was to safely initiate and advance nipple feeding for very preterm neonates (born at <32 weeks gestation) who had a respiratory morbidity requiring nasal continuous positive airway pressure therapy. A novel algorithm entitled "eating in SINC: Safe individualized nipple-Feeding Competence" was developed. Safe individualized nipple-feeding competence involves the baby, the parents, and the health care team by using infant-driven strategies, common language, and developmentally appropriate goals while supporting fragile neonates to be skilled feeders.
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Affiliation(s)
- Stacey R Dalgleish
- Foothills Medical Centre, NICU, 5th Floor, 1403 29 Street NW, Calgary, AB, T2N 2T9, Canada
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