Impact of feeding difficulties in the NICU on neurodevelopmental outcomes at 8 and 20 months corrected age in extremely low gestational age infants

Machine learning risk stratification for high-risk infant follow-up of term and late preterm infants

BACKGROUND

Term and late preterm infants are not routinely referred to high-risk infant follow-up programs at neonatal intensive care unit (NICU) discharge. We aimed to identify NICU factors associated with abnormal developmental screening and develop a risk-stratification model using machine learning for high-risk infant follow-up enrollment.

METHODS

We performed a retrospective cohort study identifying abnormal developmental screening prior to 6 years of age in infants born ≥34 weeks gestation admitted to a level IV NICU. Five machine learning models using NICU predictors were developed by classification and regression tree (CART), random forest, gradient boosting TreeNet, multivariate adaptive regression splines (MARS), and regularized logistic regression analysis. Performance metrics included sensitivity, specificity, accuracy, precision, and area under the receiver operating curve (AUC).

RESULTS

Within this cohort, 87% (1183/1355) received developmental screening, and 47% had abnormal results. Common NICU predictors across all models were oral (PO) feeding, follow-up appointments, and medications prescribed at NICU discharge. Each model resulted in an AUC > 0.7, specificity >70%, and sensitivity >60%.

CONCLUSION

Stratification of developmental risk in term and late preterm infants is possible utilizing machine learning. Applying machine learning algorithms allows for targeted expansion of high-risk infant follow-up criteria.

IMPACT

This study addresses the gap in knowledge of developmental outcomes of infants ≥34 weeks gestation requiring neonatal intensive care. Machine learning methodology can be used to stratify early childhood developmental risk for these term and late preterm infants. Applying the classification and regression tree (CART) algorithm described in the study allows for targeted expansion of high-risk infant follow-up enrollment to include those term and late preterm infants who may benefit most.

Pediatric Intestinal Failure Associated Eating Disorder: An Overview of the Importance of Oral Feeding in a Population at Risk for Feeding Difficulties

Achieving feeding skills and food acceptance is a multi-layered process. In pediatric intestinal failure (PIF), oral feeding is important for feeding skills development, physiologic adaptation, quality of life and the prevention of eating disorders. In PIF, risk factors for feeding difficulties are common and early data suggests that feeding difficulties are prevalent. There is a unique paradigm for the feeding challenges in PIF. Conventional definitions of eating disorders have limited application in this context. A pediatric intestinal failure associated eating disorder (IFAED) definition that includes feeding/eating skills dysfunction, psychosocial dysfunction, and the influence on weaning nutrition support is proposed.

Oral feeding trajectories and neurodevelopmental outcomes at 12 and 24 month follow-up for preterm infants

BACKGROUND

Few studies characterize feeding performance in the NICU when predicting neurodevelopmental outcomes. Our objective was to investigate the relationship between time to full oral feeds (FULL-PO) and neurodevelopmental and feeding outcomes in the first 2 years in preterm infants admitted to the NICU.

METHODS

This retrospective study included infants born between 01/01/2014-07/31/2017, gestational age < 32 weeks and/or birth weight < 1500 g. We examined feeding difficulties, cerebral palsy, and Bayley scores for those reaching FULL-PO at a post menstrual age (PMA)≤38.0 weeks (EARLY) vs.>38.0 weeks (LATE). Additionally, the oral feeding achieved at various timepoints between 36- and 42-weeks postmenstrual age (PMA) was measured to construct a timeline of oral feeding acquisition.

RESULTS

Of 192 infants, 147(77%) achieved FULL-PO EARLY and 45(23%) LATE. Comorbidities and length of stay were higher and unadjusted Bayley scores were lower at 12 months corrected age (CA) and 24 months chronological age (CH) in the LATE group. Feeding difficulties were higher in the LATE group at 24 months CH. Infants born < 27-28 weeks GA were more likely to achieve oral feeding at a later PMA. Infants with bronchopulmonary dysplasia (BPD) had significant feeding and developmental delays.

CONCLUSIONS

Establishing full oral feeds by 38.0 weeks PMA may be used as a predictor for feeding difficulties at 24 months CH. Infants born < 27-28 weeks GA and those with BPD are more likely to take extended amounts of time to achieve full oral feeding and need additional feeding support. Infants with BPD are high risk for neurodevelopmental delays.

An Exploratory Analysis of Gastrointestinal Morbidities and Feeding Outcomes Associated with Neonatal Hypoxic-Ischemic Encephalopathy With or Without Hypothermia Therapy

This study investigates the clinical profile and predictors of gastrointestinal/hepatic morbidities and feeding outcomes among neonates with hypoxic-ischemic encephalopathy (HIE). A single-center retrospective chart review of consecutive neonates >35 weeks of gestation admitted with a diagnosis of HIE between January 1, 2015, and December 31, 2020, and treated with therapeutic hypothermia, if met the institutional eligibility criteria. Outcomes assessed included necrotizing enterocolitis (NEC), conjugated hyperbilirubinemia, hepatic dysfunction, assisted feeding at discharge, and time to reach full enteral and oral feeds. Among 240 eligible neonates (gestational age 38.7 [1.7] weeks, birth weight 3279 [551] g), 148 (62%) received hypothermia therapy, and 7 (3%) and 5 (2%) were diagnosed with stage 1 NEC and stage 2-3 NEC, respectively. Twenty-nine (12%) were discharged home with a gastrostomy/gavage tube, conjugated hyperbilirubinemia (first week 22 [9%], at discharge 19 [8%]), and hepatic dysfunction (74 [31%]). Time to reach full oral feeds was significantly longer in hypothermic neonates compared with neonates who did not receive hypothermia (9 [7-12] days vs. 4.5 [3-9] days, p < 0.0001). Factors significantly associated with NEC were renal failure (odds ratio [OR] 9.24, 95% confidence interval [CI] 2.7-33), hepatic dysfunction (OR 5.69, 95% CI 1.6-26), and thrombocytopenia (OR 3.6, 95% CI 1.1-12), but no significant association with hypothermia, severity of brain injury, or stage of encephalopathy. Transient conjugated hyperbilirubinemia, hepatic dysfunction within first week of life, and need for assistive feeding are more common than NEC in HIE. Risk of NEC was associated with the severity of end-organ dysfunction in the first week of life, rather than severity of brain injury and hypothermia therapy per se.

The effects of untreated reflux on the incidence of dysphagia, oral aversion, and feeding difficulty in the NICU population

OBJECTIVES

To determine whether late-preterm and full-term neonates in the neonatal intensive care unit (NICU) with diagnosed gastroesophageal reflux (GERD) have an increased incidence of feeding difficulties, dysphagia, and oral aversion. To determine the incidence of reflux medication use in late-preterm and full-term neonates in the NICU.

METHODS

Neonates greater than 34 weeks gestational age (GA) diagnosed with reflux, who were hospitalized for at least five days, were included in the study. Neonates with anatomical anomalies that interfere with feeding are excluded. The control group included neonates greater than 34 weeks GA not diagnosed with reflux. The key outcome variables were subjective ease of feeding, oral aversion, and placement on nasogastric (NG), orogastric (OG), or requirement of total parenteral nutrition (TPN). Statistical analysis was performed using chi-squared and t-test to compare incidence of feeding difficulties between the groups. A p-value <0.05 was considered significant.

RESULTS

In neonates with a diagnosis of reflux, 42.02% had feeding difficulties (66 patients). In the control group, 30.49% of neonates had feeding difficulties (218 patients). Feeding difficulties in neonates with reflux was 11.55% higher than in the control group (p = 0.001).

CONCLUSION

Late-preterm and full-term neonates diagnosed with reflux have a higher incidence of feeding difficulties than those who did not have reflux. Only 0.86% of neonates diagnosed with reflux were treated with anti-reflux medications at this large tertiary care children's hospital.

Feeding and developmental outcomes after neonatal seizures-A prospective observational study

Objective

Among neonates with acute symptomatic seizures, we evaluated whether inability to take full feeds at time of hospital discharge from neonatal seizure admission is associated with worse neurodevelopmental outcomes, after adjusting for relevant clinical variables.

Methods

This prospective, 9-center study of the Neonatal Seizure Registry (NSR) assessed characteristics of infants with seizures including: evidence of brainstem injury on MRI, mode of feeding upon discharge, and developmental outcomes at 12, 18, and 24 months. Inability to take oral feeds was identified through review of medical records. Brainstem injury was identified through central review of neonatal MRIs. Developmental outcomes were assessed with the Warner Initial Developmental Evaluation of Adaptive and Functional Skills (WIDEA-FS) at 12, 18, and 24 months corrected age.

Results

Among 276 infants, inability to achieve full oral feeds was associated with lower total WIDEA-FS scores (160.2±25.5 for full oral feeds vs. 121.8±42.9 for some/no oral feeds at 24 months, p<0.001). At 12 months, a G-tube was required for 23 of the 49 (47%) infants who did not achieve full oral feeds, compared with 2 of the 221 (1%) who took full feeds at discharge (p<0.001).

Conclusions

Inability to take full oral feeds upon hospital discharge is an objective clinical sign that can identify infants with acute symptomatic neonatal seizures who are at high risk for impaired development at 24 months.

Oral stimulation for promoting oral feeding in preterm infants

BACKGROUND

Preterm infants (< 37 weeks' post-menstrual age (PMA)) are often delayed in attaining oral feeding. Normal oral feeding is suggested as an important outcome for the timing of discharge from the hospital and can be an early indicator of neuromotor integrity and developmental outcomes. A range of oral stimulation interventions may help infants to develop sucking and oromotor co-ordination, promoting earlier oral feeding and earlier hospital discharge. This is an update of our 2016 review.

OBJECTIVES

To determine the effectiveness of oral stimulation interventions for attainment of oral feeding in preterm infants born before 37 weeks' PMA.

SEARCH METHODS

Searches were run in March 2022 of the following databases: CENTRAL via CRS Web; MEDLINE and Embase via Ovid. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-randomised trials. Searches were limited by date 2016 (the date of the search for the original review) forward. Note: Due to circumstances beyond our control (COVID and staffing shortages at the editorial base of Cochrane Neonatal), publication of this review, planned for mid 2021, was delayed. Thus, although searches were conducted in 2022 and results screened, potentially relevant studies found after September 2020 have been placed in the section, Awaiting Classification, and not incorporated into our analysis.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing a defined oral stimulation intervention with no intervention, standard care, sham treatment or non-oral intervention (e.g. body stroking protocols or gavage adjustment protocols) in preterm infants and reporting at least one of the specified outcomes.

DATA COLLECTION AND ANALYSIS

Following the updated search, two review authors screened the titles and abstracts of studies and full-text copies when needed to identify trials for inclusion in the review. The primary outcomes of interest were time (days) to exclusive oral feeding, time (days) spent in NICU, total hospital stay (days), and duration (days) of parenteral nutrition. All review and support authors contributed to independent extraction of data and analysed assigned studies for risk of bias across the five domains of bias using the Cochrane Risk of Bias assessment tool. The GRADE system was used to rate the certainty of the evidence. Studies were divided into two groups for comparison: intervention versus standard care and intervention versus other non-oral or sham intervention. We performed meta-analysis using a fixed-effect model.

MAIN RESULTS

We included 28 RCTs (1831 participants). Most trials had methodological weaknesses, particularly in relation to allocation concealment and masking of study personnel. Oral stimulation compared with standard care Following meta-analysis, it is uncertain whether oral stimulation reduces the time to transition to oral feeding compared with standard care (mean difference (MD) -4.07 days, 95% confidence interval (CI) -4.81 to -3.32 days, 6 studies, 292 infants; I2 =85%, very low-certainty evidence due to serious risk of bias and inconsistency). Time (days) spent in the neonatal intensive care unit (NICU) was not reported. It is uncertain whether oral stimulation reduces the duration of hospitalisation (MD -4.33, 95% CI -5.97 to -2.68 days, 5 studies, 249 infants; i2 =68%, very low-certainty evidence due to serious risk of bias and inconsistency). Duration (days) of parenteral nutrition was not reported. Oral stimulation compared with non-oral intervention Following meta-analysis, it is uncertain whether oral stimulation reduces the time to transition to exclusive oral feeding compared with a non-oral intervention (MD -7.17, 95% CI -8.04 to -6.29 days, 10 studies, 574 infants; I2 =80%, very low-certainty evidence due to serious risk of bias, inconsistency and precision). Time (days) spent in the NICU was not reported. Oral stimulation may reduce the duration of hospitalisation (MD -6.15, 95% CI -8.63 to -3.66 days, 10 studies, 591 infants; I2 =0%, low-certainty evidence due to serious risk of bias). Oral stimulation may have little or no effect on the duration (days) of parenteral nutrition exposure (MD -2.85, 95% CI -6.13 to 0.42, 3 studies, 268 infants; very low-certainty evidence due to serious risk of bias, inconsistency and imprecision).

AUTHORS' CONCLUSIONS

There remains uncertainty about the effects of oral stimulation (versus either standard care or a non-oral intervention) on transition times to oral feeding, duration of intensive care stay, hospital stay, or exposure to parenteral nutrition for preterm infants. Although we identified 28 eligible trials in this review, only 18 provided data for meta-analyses. Methodological weaknesses, particularly in relation to allocation concealment and masking of study personnel and caregivers, inconsistency between trials in effect size estimates (heterogeneity), and imprecision of pooled estimates were the main reasons for assessing the evidence as low or very low certainty. More well-designed trials of oral stimulation interventions for preterm infants are warranted. Such trials should attempt to mask caregivers to treatment when possible, paying particular attention to blinding of outcome assessors. There are currently 32 ongoing trials. Outcome measures that reflect improvements in oral motor skill development as well as longer term outcome measures beyond six months of age need to be defined and used by researchers to capture the full impact of these interventions.

Associations between feeding and development in preterm infants in the NICU and throughout the first year of life

BACKGROUND

There is little published evidence regarding associations between feeding and development in preterm infants which could help identify infants most needing follow-up services.

AIMS

To determine if preterm infant feeding and development were predictable throughout the first year of life and identify associations with maternal factors, neonatal factors, and socioeconomic measures.

STUDY DESIGN

Prospective single-site study of the feeding and development of extremely and very preterm infants at three time points throughout the first year of life.

SUBJECTS

Infants <32 weeks gestational age were followed from neonatal intensive care unit (NICU) discharge (DC) until 12 months corrected gestational age (CGA).

OUTCOME MEASURES

Feeding and development were evaluated at NICU DC, 3 months and 12 months CGA. Maternal health, infant health, and socioeconomic measures were also recorded.

RESULTS

Significant differences were found between assessments for feeding and development at each of the three time points: NICU DC (p = 0.026), 3 months CGA (p = 0.001), and 12 months CGA (p = 0.000); however, no associations were found between feeding and development at NICU DC and 12 months CGA (p = 0.137). Of the maternal factors determined to be significant, none were consistent enough as to be considered relevant.

CONCLUSIONS

This study demonstrated that preterm infants with typical feeding and development at DC may go on to develop concerns in these areas, and those who scored abnormally at DC may perform typically during the first year of life. This study affirms the importance of NICU follow-up services to support feeding and development for all infants born <32 weeks gestation.

Nurse-Driven Interventions for Improving ELBW Neurodevelopmental Outcomes

Survival rates for extremely low-birth-weight (ELBW) infants are improving as neurodevelopmental impairment (NDI) rates stay stable, thereby increasing the overall number of infants with NDI. Although there are many determinants of NDI in this population, nutritional factors are of interest because they are readily modifiable in the clinical setting. Nurses can influence nutritional factors such as improving access to human milk feeding, using growth monitoring, establishing feeding policies, implementing oral care with colostrum, facilitating kangaroo care, and providing lactation education for the mother. All of these measures assist in leading to a decrease in NDI rates among ELBW infants.

Impact of an Infant-Driven Feeding Initiative on Feeding Outcomes in the Preterm Neonate

BACKGROUND

Poor feeding techniques result in adverse outcomes for preterm infants. Infant-driven feeding (IDF) is a structured feeding method that standardizes neonatal cue-based feedings, and matches the neurodevelopmental stage of the preterm infant. The purpose of this quality improvement project is to assess whether initiation of an IDF initiative impacts time from first nipple feed (NF) to full NF and to discharge in infants born before 35 weeks' gestational age. Secondary aims include assessment of the impact of IDF on neonatal growth and feasibility of following an IDF protocol in a level III neonatal intensive care unit (NICU).

METHODS

This quality improvement project assesses differences in time to first NF, length of hospital stay, and neonatal growth before and after usage of an IDF protocol. Eighty infants were included, 40 prior to and 40 after IDF intervention. Nurses were trained on IDF philosophy and methods prior to initiation.

RESULTS

IDF was associated with discharge at a younger corrected gestational age (CGA), attainment of ad lib feeds at a younger CGA, and shorter amount of days between first NF and discharge. Infants utilizing IDF had slower weight gain, demonstrated by a larger drop in z score in the IDF group. The medical team and bedside nurses were able to follow the IDF protocol with few exceptions.

IMPLICATIONS FOR PRACTICE/RESEARCH

IDF allows for optimization of a preterm infant's NICU stay and prepares infants for a safe discharge sooner. This could lead to increased parental satisfaction and decreased hospital cost. Further studies are indicated to ensure these benefits remain and focus on impact direct breastfeeding plays in the IDF model.

Implementation of Cue-Based Feeding to Improve Preterm Infant Feeding Outcomes and Promote Parents' Involvement

OBJECTIVE

To implement cue-based feeding for preterm infants and to assess its effects on time to achieve full oral feedings, length of stay, and parents' involvement in the feeding process.

DESIGN

A quality improvement project with a pre-post evidence-based practice implementation design.

SETTING

Level III NICU in a quaternary hospital in the U.S. Northeast.

PARTICIPANTS

Medical records of preterm infants from 23 0/7 weeks to 31 6/7 weeks gestational age who were eligible for initiation of oral feeding.

INTERVENTION/MEASUREMENTS

We implemented cue-based feeding through staff education and training. We completed a retrospective review of the medical records of 82 preterm infants before implementation and 167 preterm infants after implementation for the outcomes of time to achieve full oral feedings, length of stay, and parents' involvement in the feeding process.

RESULTS

For infants 23 0/7 weeks to 27 6/7 weeks gestation, time to achieve full oral feedings decreased by 7 days, length of stay decreased by 4.4 days, and parents' involvement in the feeding process increased by 80% from before to after implementation. For infants 28 0/7 weeks to 31 6/7 weeks, time to achieve full oral feedings decreased by 6.6 days, length of stay decreased by 2.7 days, and parents' involvement in the feeding process increased by 49% from before to after implementation. The organization saved $103,950 per year by decreasing length of stay.

CONCLUSIONS

Cue-based feeding decreased time to achieve full oral feedings, decreased length of stay, increased parents' involvement in the feeding process, and resulted in cost savings for the institution.

Effect of Formula Type and Preparation on International Dysphagia Diet Standardisation Initiative Thickness Level and Milk Flow Rates From Bottle Teats

Purpose The purpose of this study was to evaluate the effect of infant formula type and preparation (i.e., ready-to-feed vs. powder) on International Dysphagia Diet Standardisation Initiative (IDDSI) thickness level and milk flow rates from bottle teats/nipples. Method The ready-to-feed and powder formulations of the following products were tested for IDDSI thickness level, using IDDSI guidelines, and for milk flow rate, using established flow testing methods: Similac Advance, Similac For Spit-Up, Enfamil Infant, and Enfamil A.R. Analysis of variance was used to compare flow rates among formula types/preparations. Results Enfamil A.R. ready-to-feed was classified as IDDSI "slightly thick." All other formula types/preparations were found to be IDDSI "thin" liquids. The standard infant formulas (Similac Advance and Enfamil Infant) had comparable flow rates to each other, regardless of preparation (ready-to-feed and powder). The gastroesophageal reflux-specific formulas (Similac For Spit-Up and Enfamil A.R.) had slower flow rates than the standard formulas; within this category, there were significant differences in flow rates between ready-to-feed and powder. Enfamil A.R. powder had the slowest flow rate, but was the most variable. Conclusion For infants with difficulty coordinating sucking, swallowing, and breathing, clinicians and parents should consider the impact that changes to infant formula type and preparation may have on the infant's ability to safely feed.

Establishing a Foundation for Optimal Feeding Outcomes in the NICU

Many infants in the NICU experience difficulties with oral feeding, which contribute to prolonged length of stay. Oral feeding is a complex task involving sensorimotor functioning of the face, mouth, and larynx, as well as coordination of sucking, swallowing, and breathing. The care provided in the NICU starting at birth sets the stage for future oral feeding. The purpose of this article is to describe strategies that will establish a positive foundation to support optimal oral feeding. Nurses can use these strategies to protect newborns from noxious stimuli and promote positive auditory, tactile, gustatory, and olfactory experiences to optimize neurodevelopment for the complex task of feeding.