Treatment of Pediatric Patients With High-Flow Nasal Cannula and Considerations for Oral Feeding: A Review of the Literature

A Retrospective Review of Children Admitted With Acute Severe Asthma to the Paediatric Intensive Care Unit, Red Cross War Memorial Children's Hospital Between 2009 and 2019

AIM

There is limited data on the PICU outcomes of children with acute severe asthma (ASA) in South Africa. This study aims to describe the profiles and treatment of all children admitted to our PICU with ASA.

METHODS

A retrospective audit of all children admitted with ASA to the PICU at Red Cross War Memorial Children's Hospital between 01 January 2009 and 31 December 2019.

RESULTS

There were 14 592 PICU admissions over the 11-year period, of which 180 admissions (1.2%) were for ASA. The median, interquartile range (IQR) age on admission was 67 (37-93) months. Almost all children received nebulisations, steroids and magnesium sulphate before PICU admission. Half of the patients were loaded with intravenous salbutamol (n = 96; 53.3%) and about a third (n = 61; 34%) received a salbutamol infusion before PICU admission. Similar proportions received nebulisations and steroids in PICU, 34 children (19%) received magnesium sulphate again in PICU and a total of 130 children (72.2%) received a salbutamol infusion. Most children received non-invasive respiratory support (n = 167; 90.3%), and 18 children (9.7%) required mechanical ventilation for a median (IQR) of 3 (2-4) days. The median PICU stay was 1 (IQR 1-2) day and median hospital stay was 4 (IQR 3-6) days. No children died.

CONCLUSION

There has been an increasing number of children admitted to PICU with ASA over the 11-year period. There has been increased use of HFNC and the duration of PICU support is short.

Oral feeding practices in medically complex infants receiving prolonged high-flow nasal cannula support: A retrospective cohort study

AIM

To characterise the feeding profile and care pathway for infants receiving prolonged high-flow nasal cannula (HFNC) respiratory support for management of a chronic condition at one facility from January to December 2021.

METHODS

Data regarding medical history, HFNC admission details (reason for HFNC, HFNC duration, flow rate), feeding outcomes and speech pathology care were collected from electronic records of HFNC-dependent infants (requiring HFNC ≥2-3 L/kg for ≥5 consecutive days). Infants with acute respiratory conditions (e.g. bronchiolitis) were excluded.

RESULTS

This study included 24 participants (median corrected age at admission 5.3 weeks, range -6 to 18.6). Of these, 15 (60%) had a condition/s that affected more than one body system (e.g. congenital diaphragmatic hernia), requiring the care of multiple specialities. Median length of HFNC use was 37.5 days (range 11-188). Twenty (83.3%) infants were referred for speech pathology (SLP) input while on HFNC support. For those referred, frequency of SLP input was variable (0-3 sessions/week), and HFNC support requirements were the most common barrier to SLP intervention (n = 9, 45%). Twelve (54.5%) infants demonstrated improvement in their primary feeding method by discharge; however, only two (9.1%) infants were discharged on full oral feeds.

CONCLUSIONS

This study demonstrates variability in oral feeding management in infants with prolonged HFNC-dependence at our centre. Respiratory support with HFNC was identified as a barrier to progressing oral feeding. Further research is required to determine if oral feeding can be safely undertaken in this cohort. This is imperative to ensure that long-term feeding outcomes are not negatively impacted by current practice.

Caregiver experiences of oral feeding in infants on long-term high flow nasal cannula support

PURPOSE

Navigating the feeding journey of medically complex infants on long-term high flow nasal cannula support can be challenging for caregivers, especially given inconsistencies in clinical practice for oral feeding on high flow nasal cannula support. The aim of this study was to explore the perspectives of caregivers who have experienced this journey, to inform best practice care.

METHOD

This study used a generic qualitative inquiry approach. Semi-structured interviews were conducted with seven caregivers of children who had been on long-term high flow nasal cannula support as infants during 2021. Reflexive thematic analysis was used to generate meaning-united stories.

RESULT

All caregivers reported oral feeding difficulties that persisted beyond hospitalisation, resulting in demanding mental loads and care arrangements. Caregivers described how these difficulties were often exacerbated by complex medical needs and the strategies they experimented with to support oral feeding. Caregiver's experiences in the healthcare system were characterised by inconsistencies in care pathways and variable access to specialist feeding services. The importance of a collaborative relationship with healthcare professionals and a conducive hospital environment were also highlighted.

CONCLUSION

The oral feeding journey for families with infants on long-term high flow nasal cannula support was characterised by multifaceted challenges and implications. Further research is required to establish and provide consistent, family-centred, and evidence-based care for this population.

Swallowing and feeding of young children on high-flow oxygen therapy

BACKGROUND

 Oral feeding practices of young patients on high-flow oxygen (HFO2) have been controversial. Limited literature exists on this topic, but new studies suggest introducing oral feeds.

OBJECTIVE

 This study aims to describe the changes in swallowing and feeding of a group of young children on HFO2.

METHOD

 Twelve participants (mean age 34.17 months [s.d. = 3.97]) on HFO2 were assessed clinically at the bedside using the Schedule of Oral Motor Assessment. Assessments were conducted twice to determine the change in characteristics: upon approval from the managing doctor when respiratory stability on HFO2 was achieved and for a second time on the last day of receiving HFO2 (mean 2.6 days apart). Patients received standard in-patient care and speech therapy intervention.

RESULTS

 Most participants displayed typical oral motor function at initial and final assessments for liquid, puree and semi-solid consistencies. Purees and soft solid consistencies were introduced to most participants (n = 11, 91.7%). Solids and chewables were challenging for all participants during both assessments. Half of the participants displayed gagging and a wet vocal quality with thin liquids at the initial assessment only.

CONCLUSION

 This small-scale study found that HFO2 should not preclude oral diets, but in this sample, small amounts of oral feeding could be introduced with caution, in an individualised manner, and with a collaborative multidisciplinary approach. Further research is essential.Contribution: Partial oral feeding of specific consistencies was possible during the assessment of young paediatric in-patients on HFO2. Monitoring of individual patient characteristics and risk factors by a specialist feeding team is essential.

Feeding Pathway for Children on High Flow Nasal Cannula Decreases Time to Enteral Nutrition

High Flow Nasal Cannula (HFNC) is commonly used for children with respiratory failure, yet no standardized guidelines exist on how to initiate, escalate, and maintain enteral nutrition (EN) for these patients. EN in critically ill children is associated with decreased hospital length of stay, decreased ventilator days, and fewer acquired infections. We aimed to decrease the mean time to EN initiation by 50% after the start of HFNC in 6 months.

METHODS

This quality improvement project used the Model for Improvement to inform interventions. A multidisciplinary team created an EN pathway for critically ill patients on HFNC. We conducted Plan-Do-Study-Act cycles related to implementing a standardized pathway for EN on HFNC. The primary outcome was time to EN initiation once on HFNC. Secondary outcomes were time to goal caloric EN, duration of HFNC, and adverse events. Outcomes were plotted on statistical process control charts and analyzed for special cause variation between baseline and intervention periods.

RESULTS

We included 112 patients in the study. Special cause variation occurred for both primary and secondary outcomes. The mean time to EN initiation decreased from 24.6 hours to 11.7 hours (47.5%). Mean time to goal feeds decreased from 25.8 hours to 15.1 hours (58.5%). Mean HFNC duration did not show any special cause variation. There were no episodes of aspiration.

CONCLUSION

Implementation of a standardized pathway for EN on patients receiving HFNC resulted in decreased time to initiation of EN and time to goal caloric EN with no significant increase in adverse events.