Minimal enteral nutrition during neonatal hypothermia treatment for perinatal hypoxic-ischaemic encephalopathy is safe and feasible

A prospective study describing splanchnic NIRS and clinical outcomes in encephalopathic neonates receiving minimal enteral nutrition during therapeutic hypothermia

OBJECTIVE

To compare regional splanchnic oxygenation (SrSO2) levels and clinical outcomes between infants who received minimal enteral nutrition (MEN) during Therapeutic Hypothermia (TH), and those who did not.

STUDY DESIGN

A prospective, interventional cohort study with a historic control group at two Regional Perinatal Centers (NCT05471336).

RESULTS

Participant demographics and clinical illness severity were similar between MEN (n = 40) and control (n = 40) groups. There were no significant safety events. SrSO2 levels were normal in both groups throughout. Subjects that received MEN experienced fewer central line days (5.8 v 6.9, p = 0.005) and higher rates of human milk feeding (77% v 46%, p = 0.010), and achieved full oral feeds sooner (9.9 v 13.4 days, p = 0.043).

CONCLUSION

Splanchnic tissue oxygenation was normal in both groups, and similar between groups throughout TH. Providing MEN during TH appears safe and effective, resulting in several important clinical benefits.

Impact of dexmedetomidine during hypothermia on initiation of enteral feeding in newborns with hypoxic-ischemic encephalopathy

BackgroundAfter early studies suggested safety and potential for benefit of dexmedetomidine use in neonatal hypoxic-ischemic encephalopathy (HIE), our neonatal intensive care unit (NICU) decided to transition from morphine to dexmedetomidine as our standard sedative during therapeutic hypothermia (TH). The primary aim was to monitor the possible side effects of transitioning from morphine to dexmedetomidine with a primary goal of reducing the days to initiation of enteral feeds to less than 3 days, with the hypothesis that the gastrointestinal motility effects of morphine may have been hindering feeding progress during TH. The secondary aim was to determine rates of hemodynamically significant bradycardia.MethodsThis was a prospective quality improvement study using a retrospective comparison group to determine the comfort, hemodynamic, and early feeding effects of a clinical change in sedation management from morphine to dexmedetomidine. We included infants born at ≥35 weeks of gestation receiving hypothermia for hypoxic-ischemic encephalopathy (HIE) from 2017 to 2023.ResultsData were collected from 107 infants: 48 morphine, 35 dexmedetomidine, and 24 neither. Heart rate was lower in the morphine and dexmedetomidine groups compared to no sedation. Blood pressures, pain scores, and blanket temperatures were not different between groups. Infants receiving dexmedetomidine initiated enteral feeds earlier than either of the other groups and reached full enteral feeds earlier than the no treatment group but not the morphine group.ConclusionsThis study supports a growing body of literature suggesting dexmedetomidine is a well-tolerated alternative to opioids during hypothermia for HIE.

Effects of Therapeutic Hypothermia and Minimal Enteral Nutrition on Short-Term Outcomes in Neonates with Hypoxic-Ischemic Encephalopathy: A 10-Year Experience from Oman

BACKGROUND

Therapeutic hypothermia (TH) is the standard treatment for moderate to severe hypoxic-ischemic encephalopathy (HIE) in developed countries, but data on its safety and efficacy in low-middle-income countries are limited and often conflicting. The impact of enteral feeding during TH remains inadequately explored. We aimed to examine TH's effects on mortality and brain injury and evaluate the safety and effectiveness of minimal enteral feeding during TH. Here, we report our single-center experience with TH over a 10-year period".

METHODS

A total of 187 neonates with moderate to severe HIE who underwent cooling were included in this retrospective study. Post-rewarming MRI scans were scored using a validated MRI scoring system. The primary outcomes were mortality and composite outcomes of mortality and brain injury.

RESULTS

The mortality rate was 3% in moderate and 25% in severe cases (p < 0.001). Overall, 85% (160/187) of neonates received minimal enteral nutrition. Multivariate regression analysis revealed that the severity of HIE at admission (OR 3.4 (1.03-11.6); p < 0.04) and gestational age (OR: 0.624 (0.442-0.882); p < 0.008) were independent predictors of composite outcomes of death and brain injuries. MRI score was a strong predictor of mortality (AUC: 0.89; p < 0.001) and of ability to orally feed at discharge (AUC: 0.73; p < 0.001).

CONCLUSIONS

Mortality rates associated with TH in infants with moderate-severe HIE align with those in high-income countries, and minimal enteral feeding during TH is safe. The severity of HIE, MRI scores, and feeding status are important predictors of outcomes.

Costs of Care for Neonates with Hypoxic-Ischemic Encephalopathy Treated with Therapeutic Hypothermia and Validation of the Canadian Neonatal Network Costing Algorithm

Objective

Therapeutic hypothermia (TH) is the standard treatment for neonates with hypoxic-ischemic encephalopathy (HIE). Validated cost estimates are required to better evaluate the cost-effectiveness of additional interventions during TH. The goal of this study is to identify clinical factors associated with costs of care and validate the Canadian Neonatal Network (CNN) costing algorithm for neonates with HIE receiving TH.

Study design

Single-center retrospective cohort study among neonates with HIE treated with TH in a tertiary neonatal intensive care unit from 2016 to 2018. Actual costs per patient were obtained from the hospital cost accounting system, Coût par Parcours de Soinset de Services, and linked to patient data. Estimated costs per patient were calculated using the CNN case-costing algorithm. Neonates were grouped into cost tertiles to identify characteristics of high resource users. Comparisons of actual costs and estimated costs were performed across 8 cost domains.

Results

Among 98 neonates treated with TH, 77 (79%) had mild-moderate HIE and 21 (21%) had severe HIE on admission. Factors associated with higher costs were severity of HIE and other markers of disease severity (seizures, mechanical ventilation, length of stay, and presence of brain injury on magnetic resonance imaging). Total median cost per neonate was $24,692 [IQR: $17,466; $39,234], which highly correlated with the CNN algorithm (median: $28 558 [IQR: $23 644; $40 704]) (R = 0.93, P < .01). The mean difference in total costs between estimates was $5339 (95% CI: $2697, $7981). There was a moderate-to-strong correlation between actual and estimated costs in 5/8 cost domains (R range: 0.68-0.98).

Conclusions

Severity of HIE and other markers of disease severity were associated with higher hospital costs. The CNN costing algorithm cost estimates for neonates with HIE treated with TH highly correlate with actual costs but overestimates the costs by approximately 15%.

Practice Variations for Therapeutic Hypothermia in Neonates with Hypoxic-ischemic Encephalopathy: An International Survey

OBJECTIVE

To evaluate variations in management of therapeutic hypothermia (TH) for neonatal hypoxic-ischemic encephalopathy (HIE) among international clinical sites and to identify areas for harmonization.

STUDY DESIGN

An electronic survey was sent to Children's Hospitals Neonatal Consortium site sponsors, Canadian Neonatal Network site investigators, members of the Newborn Brain Society, and American Academy of Pediatrics Neonatology chiefs.

RESULTS

One hundred five sites responded, with most from high-income regions (n = 95). Groupings were adapted from the United Nations regional groups: US (n = 52 sites); Canada (n = 20); Western Europe and other states excluding Canada and US Group (WEOG, n = 18); and non-WEOG (central and eastern Europe, Asia, Africa, Latin America, and Caribbean, n = 15). Regional variations were seen in the eligibility criteria for TH, such as the minimum gestational age, grading of HIE severity, use of electroencephalography, and the frequency of providing TH for mild HIE. Active TH during transport varied among regions and was less likely in smaller volume sites. Amplitude-integrated electroencephalogram and/or continuous electroencephalogram to determine eligibility for TH was used by most sites in WEOG and non-WEOG but infrequently by the US and Canada Groups. For sedation during TH, morphine was most frequently used as first choice but there was relatively high (33%) use of dexmedetomidine in the US Group. Timing of brain magnetic resonance imaging and neurodevelopmental follow-up were variable. Neurodevelopmental follow occurred earlier and more frequently, although for a shorter duration, in the non-WEOG.

CONCLUSIONS

We found significant variations in practices for TH for HIE across regions internationally. Future guidelines should incorporate resource availability in a global perspective.

Hemorrhagic stroke in children

Hemorrhagic stroke (HS) in childhood accounts for almost 50% of childhood strokes, is among the top ten causes of deaths, or determines lifelong disability. These facts form significant socio-economic and demographic problems. The purpose of this review is to analyze current knowledge about HS in children. The data on HS terminology are presented, taking into account the International Classification of Diseases 11 edition. Attention is paid to the epidemiology of HS in children, including the results of individual local studies. The risk factors of HS in children were studied with an analysis of the causal, pathophysiological mechanisms of HS of various etiologies. The ideas about the clinical manifestations of HS in children are described. The analysis of HS treatment in children was carried out with an emphasis on achievements in neurointensive therapy of the acute period of HS. This review also includes information on the outcomes of HS in children.

The effects of nutrition on mesenteric oxygenation among neonates with neonatal encephalopathy: a randomized clinical trial

BACKGROUND

We aimed to evaluate the effects of minimal enteral nutrition (MEN) on mesenteric blood flow and oxygenation with Doppler USG and Near Infrared Spectroscopy (NIRS) during therapeutic hypothermia (TH) in babies with HIE.

METHODS

This prospective, randomized-controlled study was composed of infants receiving MEN (study group, n = 30) and infants who were not fed (control group, n = 30) during hypothermia. Infants were monitored continuously with NIRS and mesenteric blood flow velocities were measured with Doppler USG before and after feeding.

RESULTS

The mean gestational age and birth weight for the study and control group were 38.73 ± 1.5-39.09 ± 1.02 weeks and 3076 ± 280.4-3295 ± 391 grams, respectively. Time to reach full enteral nutrition and hospital stay were significantly shorter in the study group (p = 0.049, p = 0.016). Infants in the study group experienced less feeding intolerance (p = 0.006). No infant developed necrotizing enterocolitis (NEC) in both groups. No difference was determined in pre- and post-feeding cerebral rSO2 measurements during TH and normothermia. Mesenteric rSO2, CSOR, and mesenteric blood flow measurements in the study group during normothermia were significantly increased, respectively (p = 0.03, p < 0.01, p < 0.01).

CONCLUSION

In our study, we observed that MEN during TH does not lead to a significant change in cerebral and mesenteric oxygenation. Although we did not observe an increase in blood flow and oxygenation, the absence of NEC and a lower incidence of feeding intolerance in the study group may suggest that feeding during TH is safe and feasible.

IMPACT

MEN during TH treatment does not lead to a significant change in cerebral and mesenteric oxygenation. This is the first study evaluating the effects of MEN on mesenteric oxygenation and blood flow velocities in infants with hypoxic-ischemic encephalopathy during TH with Doppler USG and NIRS, concomitantly. MEN during TH may be safe and feasible.

Growth trajectories and need for oral feeding support among infants with neonatal encephalopathy treated with therapeutic hypothermia

OBJECTIVE

Identify feeding supports required among infants with neonatal encephalopathy and determine growth trajectories to 3 years.

STUDY DESIGN

Single-center retrospective cohort study of 120 infants undergoing therapeutic hypothermia. Logistic regression and stratified analyses identified whether clinical factors, EEG-determined encephalopathy severity, and MRI-based brain injury predict feeding supports (nasogastric tube, oral feeding compensations) and growth.

RESULTS

50.8% of infants required feeding supports in the hospital, decreasing to 14% at discharge. Moderate-to-severe encephalopathy and basal ganglia injury predicted feeding support needs. Yet, 35% of mildly encephalopathic infants required gavage tubes. Growth trajectories approximated expected growth of healthy infants.

CONCLUSION

Infants with neonatal encephalopathy-even if mild-frequently experience feeding difficulties during initial hospitalization. With support, most achieve full oral feeds by discharge and adequate early childhood growth. Clinical factors may help identify infants requiring feeding support, but do not detect all at-risk infants, supporting routine screening of this high-risk population.

Enteral nutritional strategy during therapeutic hypothermia: who? when? what?

Background

There are no guidelines regarding enteral feeding (EF) of infants with hypoxic-ischemic encephalopathy (HIE) during and shortly after therapeutic hypothermia; consequently, clinical practice is, to date, still variable. The objective of this study is to assess whether a minimal EF strategy during therapeutic hypothermia may be associated with a shorter time to full EF of infants with HIE and to identify the clinical variables that independently affect the time to full EF.

Methods

A retrospective study, covering the period from 1 January 2015 to 30 June 2022 was performed at the Neonatal Intensive Care Unit of the Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, which compared infants with HIE who received minimal EF during therapeutic hypothermia with those who did not.

Results

Seventy-eight infants received minimal EF during therapeutic hypothermia, while 75 did not. Infants who were fed reached full EF significantly faster than those who were not. Moreover, they received parenteral nutrition and maintained central venous lines for a shorter time. A multivariate analysis, taking into account the variable of clinical severity, confirmed that minimal EF is an independent beneficial factor for reaching full EF in a shorter time and mechanical ventilation and seizures are independent factors for a longer time to full EF.

Conclusions

Minimal EF during therapeutic hypothermia is associated with a shorter time to full EF in stable infants with HIE. Further prospective studies are needed to better define the enteral nutrition strategy for infants during therapeutic hypothermia, regardless of the severity of clinical conditions.

Nutrition of Newborns with Hypoxic-Ischaemic Encephalopathy during Therapeutic Hypothermia - A Survey of Practice in Polish Neonatal Care Units

BACKGROUND

The nutritional practice for newborns with hypoxic-ischaemic encephalopathy during therapeutic hypothermia differs among Polish neonatal care units, as no guidelines are provided. We assessed the prevailing procedures.

MATERIAL AND METHODS

Data was collected through an anonymous, web-based questionnaire. We surveyed aspects of the current nutritional practices and the reasoning behind the choice of the feeding strategy.

RESULTS

Thirty-one responses were obtained (31/33, 94%). Based on participants' estimations, 342 newborns are diagnosed with hypoxic-ischaemic encephalopathy and qualified for therapeutic hypothermia annually. Among them, almost ⅓ is fed exclusively parenterally, while 71% both ways-parenterally and enterally. In the vast majority of units, the introduction of enteral nutrition takes place during the first 48 hours of therapeutic hypothermia, and breast milk is primarily provided, although with substantial first feeding volume differentiation (an average of 2,9 ml/kg (0,3 - 10ml/kg)). Adverse events, such as necrotising enterocolitis, sepsis, and glycemia level disturbances that derive from the initiation of enteral nutrition, are difficult to estimate as no official statistics are provided.

CONCLUSIONS

The majority of newborns after hypoxic-ischaemic encephalopathy treated with therapeutic hypothermia are fed both parenterally and enterally during the procedure, predominantly with expressed or donor breast milk. However, due to the lack of nutritional guidelines, significant variability of nutritional strategies concerning initiation time, type and volume of enteral feeds given is noted. Therefore, further studies are required to clarify feeding recommendations.

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.

To feed or not to feed during therapeutic hypothermia in asphyxiated neonates: a systematic review and meta-analysis

The practice of withholding feed during therapeutic hypothermia (TH) in neonates with hypoxemic ischemic encephalopathy (HIE) is based on conventions rather than evidence. Recent studies suggest that enteral feeding might be safe during TH. We systematically compared the benefits and harms of enteral feeding in infants undergoing TH for HIE. We searched electronic databases and trial registries (MEDLINE, CINAHL, Embase, Web of Science, and CENTRAL) until December 15, 2022, for studies comparing enteral feeding and non-feeding strategies. We performed a random-effects meta-analysis using RevMan 5.4 software. The primary outcome was the incidence of stage II/III necrotizing enterocolitis (NEC). Other outcomes included the incidence of any stage NEC, mortality, sepsis, feed intolerance, time to full enteral feeds, and hospital stay. Six studies ((two randomized controlled trials (RCTs) and four nonrandomized studies of intervention (NRSIs)) enrolling 3693 participants were included. The overall incidence of stage II/III NEC was very low (0.6%). There was no significant difference in the incidence of stage II/III NEC in RCTs (2 trials, 192 participants; RR, 1.20; 95% CI: 0.53 to 2.71, I², 0%) and NRSIs (3 studies, no events in either group). In the NRSIs, infants in the enteral feeding group had significantly lower sepsis rates (four studies, 3500 participants, RR, 0.59; 95% CI: 0.51 to 0.67, I²-0%) and lower all-cause mortality (three studies, 3465 participants, RR: 0.43; 95% CI: 0.33 to 0.57, I²-0%) than the infants in the "no feeding" group. However, no significant difference in mortality was observed in RCTs (RR: 0.70; 95% CI: 0.28 to 1.74, I²-0%). Infants in the enteral feeding group achieved full enteral feeding earlier, had higher breastfeeding rates at discharge, received parenteral nutrition for a shorter duration, and had shorter hospital stays than the control group.  Conclusion: In late preterm and term infants with HIE, enteral feeding appears safe and feasible during the cooling phase of TH. However, there is insufficient evidence to guide the timing of initiation, volume, and feed advancement. What is Known: • Many neonatal units withhold enteral feeding during therapeutic hypothermia, fearing an increased risk of complications (feed intolerance and necrotizing enterocolitis). • The overall risk of necrotizing enterocolitis in late-preterm and term infants is extremely low (< 1%). What is New: • Enteral feeding during therapeutic hypothermia is safe and does not increase the risk of necrotizing enterocolitis, hypoglycemia, or feed intolerance. It may reduce the incidence of sepsis and all-cause mortality until discharge.

Feasibility of Minimal Enteral Nutrition During Therapeutic Hypothermia for Perinatal Asphyxia: A Five-Year Multicenter Experience from South India

Limited evidence shows minimal enteral nutrition (MEN) during therapeutic hypothermia (TH) in neonates to be feasible and have benefits of shorter time to full-feeds. This study aimed to assess the feasibility of MEN during TH. MEN was initiated after 12 h if there were no altered aspirates, abdominal distension, and inotrope requirement. The authors retrospectively analyzed the records from May 2017 to April 2022. The number of episodes of feed intolerance and the length of hospital stay were the key outcomes. A total of 99 neonates were fed during cooling. MEN could be initiated at a median duration (IQR) of 24 (24-30) h. There were 9 (9%) neonates with feed intolerance during TH. None had necrotizing enterocolitis. Ninety-two (93%) neonates were discharged, with a median hospital stay (IQR) of 9 d (6-15). Hence, MEN during TH is feasible and provides a rationale for future controlled trials.

Early versus delayed enteral nutrition for neonatal hypoxic-ischemic encephalopathy undergoing therapeutic hypothermia: a randomized controlled trial

Background

The practice of therapeutic hypothermia (TH) is widely used for neonatal hypoxic-ischemic encephalopathy (HIE) despite its corresponding feeding strategies are still controversial. This randomized controlled trial (RCT) demonstrated to evaluate the effect of early vs. delayed enteral nutrition on the incidence of feeding intolerance (FI) and other association during TH.

Methods

This single center, parallel-group, and no-blinded RCT was processed in a level III, and academic neonatal intensive care unit. Infants who were diagnosed with HIE and undertaken TH from September 2020 to August 2021 were enrolled. Participants were randomized to receive enteral nutrition either during TH/rewarming (early enteral nutrition, EEN) or after TH (delayed enteral nutrition, DEN) according to a recommend enteral feeding protocol. All data were analyzed using SPSS 26.0 software with a p-value< 0.05 was considered statistically significant.

Results

Ninety-two infants were enrolled after randomization, but 12 (13.04%) cases including 3 (3.26%) deaths were excluded from eventually analyzed, who did not initiate or discontinue the intervention. 80 cases (42 and 38 in the EEN and DEN group, respectively) who completed the interventions were eventually analyzed. Besides initial time of enteral feeds, two groups had processed the same feeding method. Total 23 (25.0%) cases developed FI, and no difference of morbidity was found between two groups (23.4% vs 26.7%, p = 0.595; Log Rank, p = 0.803). There was no case died or developed late-onset bloodstream and no difference of the incidence of hypoglycemia or weight gain was found (p > 0.05). The percentage of infants who had not reaching the goal of full enteral feeding volume between the two groups was similar (21.43% vs 23.68%, p = 0.809). The average time of parenteral nutrition, reaching full enteral feeds and hospital stay were shorter in the EEN group compared with the DEN group with significant differences (8.81 ± 1.67 vs 10.61 ± 2.06 days, p < 0.001; 9.91 ± 1.88 vs 12.24 ± 2.50 days, p < 0.001; 12.55 ± 4.57 vs 16.47 ± 5.27 days, p = 0.001 respectively).

Conclusions

Compared with delayed enteral nutrition, introduction of early enteral nutrition according to a recommend feeding strategy for neonatal HIE undergoing TH may be feasible and safe.FI is frequent in this high-risk group of infants which should not be ignored during feeding process.

Trial registration

The Chinese Clinical Trial Registry,ChiCTR2000038193, 2020-9-13, https://www.chictr.org.cn.

Variations in practices and outcomes of neonates with hypoxic ischemic encephalopathy treated with therapeutic hypothermia across tertiary NICUs in Canada

OBJECTIVE

To characterize variations in practices and outcomes for neonates with hypoxic-ischemic encephalopathy (HIE) treated with therapeutic hypothermia (TH) across Canadian tertiary Neonatal Intensive Care Units (NICUs).

STUDY DESIGN

Retrospective study of neonates admitted for HIE and treated with TH in 24 tertiary NICUs from the Canadian Neonatal Network, 2010-2020. The two primary outcomes of mortality before discharge and MRI-detected brain injury were compared across NICUs using adjusted standardized ratios (SR) with 95% CI.

RESULTS

Of the 3261 neonates that received TH, 367 (11%) died and 1033 (37%) of the 2822 with MRI results had brain injury. Overall, rates varied significantly across NICUs for mortality (range 5-17%) and brain injury (range 28-51%). Significant variations in use of inotropes, inhaled nitric oxide, blood products, and feeding during TH were identified (p values < 0.01).

CONCLUSION

Significant variations exist in practices and outcomes of HIE neonates treated with hypothermia across Canada.

Fluid Supply and Feeding Practices in Cooled Asphyxiated Newborns

Therapeutic hypothermia (TH) for 72 h is the standard treatment to reduce neurological deficits in term newborns with hypoxic-ischemic encephalopathy. There is a large variability regarding nutritional supply during TH treatment in asphyxiated newborns. We performed a retrospective multicentre study in four level I (highest level of care in Germany) NICUs, including 135 asphyxiated term newborns undergoing TH. We analyzed enteral and parenteral nutritional supply during and after TH. We correlated nutritional supply with risk factors for encephalopathy, pH, Sarnat score, mechanical ventilation, seizures, and sedation. A total of 120 of 135 neonates received enteral nutritional supply within the first 24 h, and the majority of children were fully enterally fed within the first 10 days. The grade of encephalopathy and mechanical ventilation had a significant influence on the amount of enteral fluids (p = 0.01), whereas the pH and appearance of seizures did not affect the amount of nutritional supply significantly. Furthermore, we did not observe any correlation between enteral intake and abdominal complications such as necrotizing enterocolitis. We observed a large variability of feeding regimes in the four participating NICUs. Early enteral feeding among newborns undergoing TH was performed in each NICU and was well tolerated without increased rates of complications.

Nutrition and management of glycemia in neonates with neonatal encephalopathy treated with hypothermia

Adequate nutrition and glycemic homeostasis are increasingly recognized as potentially neuroprotective for the developing brain. In the context of hypoxia-ischemia, evidence is scarce regarding optimal nutritional support and administration route, as well as the short- and long-term consequences of such interventions. In this review, we summarize current knowledge on disturbances of brain metabolism of glucose and substrates by hypoxia-ischemia, and compound effects of these mechanisms on brain injury characterized by specific patterns on EEG and MRI. Risks and benefits of nutrition delivery via parenteral or enteral routes are examined. Nutrition could mitigate adverse neurodevelopmental outcomes, and the impact of nutritional strategies and specific nutritional interventions are reviewed. Limited literature highlights the need for further studies to understand the changes in energy metabolism during and after hypoxic-ischemic injury, to optimize nutritional regimens and glucose management, and to inform the neuroprotective role of nutrition.

Nutritional management in newborn babies receiving therapeutic hypothermia: two retrospective observational studies using propensity score matching

BACKGROUND

Therapeutic hypothermia is standard of care for babies with moderate to severe hypoxic-ischaemic encephalopathy. There is limited evidence to inform provision of nutrition during hypothermia.

OBJECTIVES

To assess the association during therapeutic hypothermia between (1) enteral feeding and outcomes, such as necrotising enterocolitis and (2) parenteral nutrition and outcomes, such as late-onset bloodstream infection.

DESIGN

A retrospective cohort study using data held in the National Neonatal Research Database and applying propensity score methodology to form matched groups for analysis.

SETTING

NHS neonatal units in England, Wales and Scotland.

PARTICIPANTS

Babies born at ≥ 36 gestational weeks between 1 January 2010 and 31 December 2017 who received therapeutic hypothermia for 72 hours or who died during treatment.

INTERVENTIONS

Enteral feeding analysis - babies who were enterally fed during therapeutic hypothermia (intervention) compared with babies who received no enteral feeds during therapeutic hypothermia (control). Parenteral nutrition analysis - babies who received parenteral nutrition during therapeutic hypothermia (intervention) compared with babies who received no parenteral nutrition during therapeutic hypothermia (control).

OUTCOME MEASURES

Primary outcomes were severe and pragmatically defined necrotising enterocolitis (enteral feeding analysis) and late-onset bloodstream infection (parenteral nutrition analysis). Secondary outcomes were survival at neonatal discharge, length of neonatal stay, breastfeeding at discharge, onset of breastfeeding, time to first maternal breast milk, hypoglycaemia, number of days with a central line in situ, duration of parenteral nutrition, time to full enteral feeds and growth.

RESULTS

A total of 6030 babies received therapeutic hypothermia. Thirty-one per cent of babies received enteral feeds and 25% received parenteral nutrition. Seven babies (0.1%) were diagnosed with severe necrotising enterocolitis, and further comparative analyses were not conducted on this outcome. A total of 3236 babies were included in the matched enteral feeding analysis. Pragmatically defined necrotising enterocolitis was rare in both groups (0.5% vs. 1.1%) and was lower in babies who were fed during hypothermia (rate difference -0.5%, 95% confidence interval -1.0% to -0.1%; p = 0.03). Higher survival to discharge (96.0% vs. 90.8%, rate difference 5.2%, 95% confidence interval 3.9% to 6.6%; p < 0.001) and higher breastfeeding at discharge (54.6% vs. 46.7%, rate difference 8.0%, 95% confidence interval 5.1% to 10.8%; p < 0.001) rates were observed in enterally fed babies who also had a shorter neonatal stay (mean difference -2.2 days, 95% confidence interval -3.0 to -1.2 days). A total of 2480 babies were included in the matched parenteral nutrition analysis. Higher levels of late-onset bloodstream infection were seen in babies who received parenteral nutrition (0.3% vs. 0.9%, rate difference 0.6%, 95% confidence interval 0.1% to 1.2%; p = 0.03). Survival was lower in babies who did not receive parenteral nutrition (90.0% vs. 93.1%, rate difference 3.1%, 95% confidence interval 1.5% to 4.7%; p < 0.001).

LIMITATIONS

Propensity score methodology can address imbalances in observed confounders only. Residual confounding by unmeasured or poorly recorded variables cannot be ruled out. We did not analyse by type or volume of enteral or parenteral nutrition.

CONCLUSIONS

Necrotising enterocolitis is rare in babies receiving therapeutic hypothermia, and the introduction of enteral feeding is associated with a lower risk of pragmatically defined necrotising enterocolitis and other beneficial outcomes, including rates of higher survival and breastfeeding at discharge. Receipt of parenteral nutrition during therapeutic hypothermia is associated with a higher rate of late-onset infection but lower mortality. These results support introduction of enteral feeding during therapeutic hypothermia.

FUTURE WORK

Randomised trials to assess parenteral nutrition during therapeutic hypothermia.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN474042962.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 36. See the NIHR Journals Library website for further project information.

Feeding during neonatal therapeutic hypothermia, assessed using routinely collected National Neonatal Research Database data: a retrospective, UK population-based cohort study

BACKGROUND

Therapeutic hypothermia is standard of care in high-income countries for babies born with signs of hypoxic ischaemic encephalopathy, but optimal feeding during treatment is uncertain and practice is variable. This study aimed to assess the association between feeding during therapeutic hypothermia and clinically important outcomes.

METHODS

We did a population-level retrospective cohort study using the UK National Neonatal Research Database. We included all babies admitted to National Health Service neonatal units in England, Scotland, and Wales between Jan 1, 2010, and Dec 31, 2017, who received therapeutic hypothermia for 72 h or died during this period. For analysis, we created matched groups using propensity scores and compared outcomes in babies who were fed versus unfed enterally during therapeutic hypothermia. The primary outcome was severe necrotising enterocolitis, either confirmed at surgery or causing death. Secondary outcomes include pragmatically defined necrotising enterocolitis (a recorded diagnosis of necrotising enterocolitis in babies who received at least 5 consecutive days of antibiotics while also nil by mouth during their neonatal unit stay), late-onset infection (pragmatically defined as 5 consecutive days of antibiotic treatment commencing after day 3), survival to discharge, measures of breastmilk feeding, and length of stay in neonatal unit.

FINDINGS

6030 babies received therapeutic hypothermia, of whom 1873 (31·1%) were fed during treatment. Seven (0·1%) babies were diagnosed with severe necrotising enterocolitis and the number was too small for further analyses. We selected 3236 (53·7%) babies for the matched feeding analysis (1618 pairs), achieving a good balance for all recorded background variables. Pragmatically defined necrotising enterocolitis was rare in both groups (incidence 0·5%, 95% CI 0·2-0·9] in the fed group vs 1·1% [0·7-1·4] in the unfed group). The enterally fed group had fewer pragmatically defined late-onset infections (difference -11·6% [95% CI -14·0 to -9·3]; p<0·0001), higher survival to discharge (5·2% [3·9-6·6]; p<0·0001), higher proportion of breastfeeding at discharge (8·0% [5·1-10·8]; p<0·0001), and shorter neonatal unit stays (-2·2 [-3·0 to -1·2] days; p<0·0001) compared with the unfed group.

INTERPRETATION

Necrotising enterocolitis is rare in babies receiving therapeutic hypothermia. Enteral feeding during hypothermia is safe and associated with beneficial outcomes compared with not feeding, although residual confounding could not be completely ruled out. Our findings support starting milk feeds during therapeutic hypothermia.

FUNDING

UK National Institute for Health Research Health Technology Assessment programme 16/79/13.

Outcomes improved with human milk intake in preterm and full-term infants

This review highlights clinical outcomes of human milk from infancy through adulthood. Human milk outcomes of both preterm and term infants, including critically ill term infants (such as infants with congenital heart disease and those requiring therapeutic hypothermia) are summarized. Several human milk diets are identified to reduce the risk of specific diseases. Emerging research of newly discovered components of human milk are also reviewed. Human milk has significant effects on the gut microbiome, somatic growth, and neurocognitive outcomes. Continued research promises to improve donor human milk and donor milk derived products to achieve better outcomes for infants who do not receive their own mother's milk. The promotion of human milk is well-founded on evidence from the previous half century.

Oropharyngeal Dysphagia in Breastfeeding Neonates with Hypoxic-Ischemic Encephalopathy on Therapeutic Hypothermia

Purpose: To identify symptoms of oropharyngeal dysphagia (OPD) in breastfeeding neonates with hypoxic-ischemic encephalopathy (HIE) on therapeutic hypothermia (TH). Early identification of feeding problems in neonates with HIE by speech-language therapists (SLTs) may prevent secondary complications of OPD such as aspiration pneumonia and death. Materials and Methods: Twenty-eight full-term neonates with HIE (mean chronological age = 4.5 days) and 30 healthy term controls were prospectively recruited for this case-control study. Participants with HIE (mild [n = 15], moderate [n = 11], severe [n = 2]), diagnosed by pediatricians, received whole-body TH. Feeding was clinically evaluated by an SLT using the Preterm Infant Breastfeeding Behavior Scale. Results: Twenty-five neonates (89.2%) had at least one symptom of OPD. Falling asleep during feeding, noticeable oral secretions, coughing, and flaring nostrils were symptoms of OPD most frequently identified. The HIE group displayed limited arousal during breastfeeding and had less obvious rooting, shallower latching onto the breast, and more single sucks in comparison to term newborns. The HIE group had significantly more closed eyes and minimal movement during breastfeeding, while controls showed the quiet-alert state ideal for breastfeeding. Conclusions: OPD was identified in the majority of infants with HIE. Underlying the appearance of an inactive neonate with HIE may be OPD that could be overlooked if not investigated. Interprofessional collaboration between SLTs, pediatricians and nurses to determine feeding-readiness is imperative. SLTs may assist in decision-making to improve safety of breastfeeding in this population. This study contributes to the small body of research on early breastfeeding of neonates with HIE.

Gastrointestinal hemodynamic changes during therapeutic hypothermia and after rewarming in neonatal hypoxic-Ischemic encephalopathy

BACKGROUND

Hypoxic-ischemic encephalopathy (HIE) is associated with disturbances in visceral blood flow velocities. Therapeutic Hypothermia (TH) is a standard of care; however, its impact on gastrointestinal blood flow in infants with HIE is unknown. The objective of this study was to assess gastrointestinal (GI) blood flow and left ventricle output (LVO) in infants with hypoxic-ischemic encephalopathy during whole body TH and after rewarming.

METHODS

Serial echocardiography and Doppler evaluation of intestinal blood flow (celiac (CA) and superior mesenteric (SMA) arteries) were prospectively performed in a cohort of 20 newborn infants with HIE at 4 time points during hypothermia and after rewarming. Demographic, clinical and biochemical data were collected and analyzed for their relevance.

RESULTS

Median gestational age and birth weight was 40 weeks (37-41) and 3410 g (2190-4950) respectively. Celiac and mesenteric artery flow remained low during hypothermia and rose significantly after rewarming [peak systolic velocity in CA (0.63 m/s to 0.77 m/s, p = 0.004) and SMA (0.43 m/s to 0.55 m/s, p = 0.001)]. This increase was temporally associated with increased left ventricular output (106 ml/kg/min to 149 ml/kg/min, p < 0.0001). Median age to reach 25% of the feeds was 5 days (1-7 days). All patients survived.

CONCLUSIONS

CA and SMA blood flow velocity and LVO did not vary during hypothermia but rose after rewarming. This may suggest protective effect of therapeutic hypothermia on gastrointestinal system. The association of these physiological changes with neonatal outcome needs further assessment.

Hypothermia for newborns with hypoxic-ischemic encephalopathy

Therapeutic hypothermia is a standard of care for infants ≥36 weeks gestational age (GA) with moderate-to-severe hypoxic-ischemic encephalopathy. Because some studies included infants born at 35 weeks GA, hypothermia should be considered if they meet other criteria. Cooling for infants <35 weeks GA is not recommended. Passive cooling should be started promptly in community centres, in consultation with a tertiary care centre neonatologist, while closely monitoring the infant's temperature. Best evidence suggests that maintaining core body temperature between 33°C and 34°C for 72 hours, followed by a period of rewarming of 6 to 12 hours, is optimal. Antiepileptic medications should be used when clinical or electrographic seizures are present. Maintaining serum electrolytes and glucose within normal ranges, and avoiding hypo- or hypercarbia and hyperoxia, are important adjunct treatments. A brain magnetic resonance image (MRI) is advised shortly after rewarming and, in cases where earlier findings do not match the clinical picture, a repeat MRI after 10 days of life is suggested. Multidisciplinary neurodevelopmental follow-up is recommended.

Enteral Feeding as an Adjunct to Hypothermia in Neonates with Hypoxic-Ischemic Encephalopathy

BACKGROUND

Withholding enteral feedings during hypothermia lacks supporting evidence.

OBJECTIVES

We aimed to determine if minimal enteral nutrition (MEN) during hypothermia in patients with hypoxic-ischemic encephalopathy was associated with a reduced duration of parenteral nutrition, time to full oral feeds, and length of stay, but would not be associated with increased systemic inflammation or feeding complications.

METHODS

We performed a pilot, retrospective, matched case-control study within the Florida Neonatal Neurologic Network from December 2012 to May 2016 of patients who received MEN during hypothermia (n = 17) versus those who were not fed (n = 17). Length of stay, feeding-related outcomes, and brain injury identified by MRI were compared. Serum inflammatory mediators were measured at 0-6, 24, and 96 h of life by multiplex assay. MRI were scored using the Barkovich system.

RESULTS

MEN subjects had a reduced length of hospital stay (mean 15 ± 11 vs. 24 ± 19 days, p < 0.05), days receiving parenteral nutrition (7 ± 2 vs. 11 ± 6, p < 0.05), and time to full oral feeds (8 ± 5 vs. 18 ± 18, p < 0.05). MEN was associated with a significantly reduced serum IL-12p70 at 24 and 96 h (p < 0.05). Brain MRI scores were not significantly different between groups.

CONCLUSION

MEN during hypothermia was associated with a reduced length of stay and time to full feeds, but did not increase feeding complications or systemic inflammation.

Parental perceptions of hypothermia treatment for neonatal hypoxic-ischaemic encephalopathy

AIMS

Hypothermia Treatment (HT) is now the standard care for neonatal hypoxic-ischaemic encephalopathy (HIE). We conducted a survey to explore parental perceptions of HT as there is little information about this in the current literature.

METHODS

Postal questionnaire survey included families (n = 51) whose babies received HT at Princess Anne Hospital, Southampton, UK, with 23 questions covering communication, clinical management, follow-up, and care in general. Statistical analysis of descriptive and analytical tests were done using Minitab 16.

RESULTS

The response rate was 60.8%. All parents had concerns amongst which perceptions of pain and distress were described by 41%. Temporary concerns about bonding were common (83.8%), more so in babies transferred from other hospitals (p = .04). Only 61.3% felt they had a good understanding of HT. The need for improvements in the quality (71%) and frequency of communication (48.3%) were also highlighted.

CONCLUSIONS

Parents were worried about pain and distress, bonding and about outcomes after HT. Consistency in communication, regular updates, involvement of parents in decision making, strong support mechanisms and balanced discussions about long term outcomes at an early stage are of high importance to families whose babies undergo HT.

Breastfeeding and swallowing in a neonate with mild hypoxic-ischaemic encephalopathy

BACKGROUND

Specific breastfeeding and swallowing characteristics in neonates with hypoxic-ischaemic encephalopathy (HIE) have not yet been well described in the literature. Considering the relatively high incidence of HIE in resource-poor settings, speech-language therapists should be cognisant of the feeding difficulties in this population during breastfeeding.

OBJECTIVE

To systematically describe the breastfeeding and swallowing of a single case of a neonate diagnosed with mild HIE from admission to discharge.

METHOD

A case study of a 2-day old neonate with mild HIE in a neonatal intensive care unit at an urban teaching hospital, is presented. Data were prospectively collected during four sessions in a 12-day period until the participant's discharge. Feeding and swallowing were assessed clinically, as well as instrumentally using a video-fluoroscopic swallow study.

RESULTS

After parenteral feeding, nasogastric tube feeding commenced. Breastfeeding was introduced on Day 6, as it was considered a safe option, and revealed problematic rooting, shallow latching, short sucking bursts, infrequent swallowing, and a drowsy state of arousal, with coughing and choking. No penetration or aspiration was identified instrumentally. After 13 days, the neonate was breastfeeding safely.

CONCLUSION

Although the pharyngeal stage of swallowing was intact, symptoms of oral stage dysphagia were revealed using a combination of clinical and instrumental measures. Breastfeeding difficulties were identified, exacerbated by poor state regulation, which lead to prolonged hospitalisation. The case study highlights the unexpected long duration of feeding difficulties in an infant with mild HIE and indicates further research.

Survey of nutritional practices during therapeutic hypothermia for hypoxic-ischaemic encephalopathy

OBJECTIVE

To evaluate current nutritional practices during and after therapeutic hypothermia (TH) for infants with hypoxic-ischaemic encephalopathy (HIE) in UK neonatal units.

STUDY DESIGN

Email survey of neonatal clinicians.

SETTING

UK neonatal units providing active TH.

PATIENTS

Neonates cooled for HIE.

METHODS

Email survey including questions regarding the timing of starting enteral feeds, volumes, frequency and parenteral nutrition (PN) use and availability of guidelines.

RESULTS

Forty-nine responses were received (49/69, 71%). The rate of enteral feeding during TH and rewarming was 59% (29/49). There was a significant linear trend for the increase in the proportion of units starting enteral feeds (p=0.001) during TH. As compared with post-TH period, significantly lower milk volumes were started during TH (median (range): 7.5 mL/kg/day (1.5-24) vs 17.5 mL/kg/day (7.5-30), p=0.0004). During TH, breast milk was primarily used by 52% of units predominantly as 2-3 hourly feeds, and volumes were increased as tolerated in 55% of units. Only 29% (14/49) of units used PN, with 86% (12/14) of those offering enteral feeds during PN. Guidelines for feeding during TH were available in 31% (15/49) of units.

CONCLUSIONS

Many neonatal clinicians offer enteral feeds predominantly using expressed breast milk, with or without PN, during TH, although with huge variability. The heterogeneity in the nutritional practice underscores the need for assessing the safety of both enteral and parenteral feeding during TH.

"Cool" Topic: Feeding During Moderate Hypothermia After Intracranial Hemorrhage

BACKGROUND

Therapeutic moderate hypothermia (MH; T _core 33°C-34°C) is being studied for treatment of spontaneous intracerebral hemorrhage (ICH). Nutrition assessment begins with accurate basal metabolic rate (BMR) determination. Although early enteral nutrition (EN) is associated with improved outcomes, it is often deferred until rewarming. We sought to determine the accuracy of predictive BMR equations and the safety and tolerance of EN during MH after ICH.

MATERIALS AND METHODS

Patients were randomized to 72 hours of MH or normothermia (NT; T _core 36°C-37°C). Harris-Benedict (BMR-HB) and Penn-State equation (BMR-PS) calculations were compared with indirect calorimetry (IC) at day (D) 0 and D1-3. Patients with MH received trophic semi-elemental gastric EN. Occurrences of feeding intolerance, gastrointestinal (GI)-related adverse events, and ventilator-associated pneumonia (VAP) were analyzed with a double-sided matched pairs t test.

RESULTS

Thirteen patients with ICH participated (6 MH, 7 NT). Mean time to initiate EN: 29.9 (MH) vs 18.4 (NT) hours ( P = .046). Average daily EN calories received D0-3: 398 (MH) vs 1006 (NT) ( P < .01). Three patients with MH experienced high gastric residuals prior to prokinetic agents, 1 had mild ileus, and 1 patient with NT vomited. No GI-related adverse events were reported. One patient with MH and 1 patient with NT had VAP. Two patients with MH received IC, and from D0 to D1-3, BMR-HB remained stable (1331 kcal), BMR-PS decreased (1511 vs 1145 kcal, P = .5), and IC decreased (1413 vs 985 kcal, P = .2).

CONCLUSIONS

In patients with ICH undergoing MH, resting energy expenditure is decreased and predictive equations overestimate BMR. EN is feasible, although delayed EN initiation, high gastric residuals, and less EN provision are common. Future studies should focus on EN initiation within 24 hours, advanced EN rates, and postpyloric feeds during hypothermia.