Individualising care in severe bronchopulmonary dysplasia: a series of N-of-1 trials comparing transpyloric and gastric feeding

Gastroesophageal reflux during postpyloric versus gastric tube feeding in preterm infants with bronchopulmonary dysplasia

BACKGROUND

Whether postpyloric feeding reduces gastroesophageal reflux (GER) in very preterm infants with bronchopulmonary dysplasia (BPD) is uncertain.

METHODS

Prospective observational study comparing GER profiles measured using 24-h esophageal pH-impedance monitoring in infants with BPD receiving clinically prescribed postpyloric (n = 21) or gastric (n = 24) tube feeding.

RESULTS

Participants (median gestational age 25.0 weeks, IQR 24.1-26.9) underwent testing at a median postmenstrual age of 46.6 weeks (IQR 42.7-52.4). The number of GER episodes recorded by impedance varied widely (median 27, range 1-195). Postpyloric versus gastric feeding was associated with fewer GER episodes (median, IQR: 16, 5-41 vs. 40, 19-60; p = 0.07) and less exposure of the proximal esophagus to reflux (median duration, IQR: 0.1 min, 0.005-0.6 vs. 0.77 min, 0.16-1.8; p = 0.045), but a higher proportion of acidic (pH < 4) GER episodes (median, IQR: 91%, 70-100 vs. 31%, 16-54; p < 0.001).

CONCLUSION

Postpyloric feeding may reduce total GER burden but increase the relative proportion of acidic GER in infants with BPD.

Use of transpyloric feeds in extremely low birth weight infants at risk of severe bronchopulmonary dysplasia-a single center experience

Introduction

The incidence of severe BPD (sBPD), defined as needing oxygen or positive pressure at 36 weeks corrected gestational age (CGA), has remained unchanged. These infants are at risk for developing late pulmonary hypertension (LPHN) or needing surgical interventions such as Gastrostomy Tubes (GT) or Tracheostomy Tubes (TT). The finding of pepsin in the lungs of infants who were extremely low birth weight (ELBW) with sBPD has led to the speculation that gastroesophageal reflux (GER) and aspiration could contribute to their lung disease. Micro-aspiration-reducing strategies such as Transpyloric feeds (TpF) have not been well studied.

Objectives

To compare ELBW infants with sBPD managed with or without TpF and determine the difference between the two groups for (i) illness severity, (ii) LPHN, (iii) need for GT, and (iv) TT; the secondary aim was to study the TpF group to (i) evaluate the change in Respiratory Severity Score (RSS) before and after TpF, and (ii) evaluate the time taken to affect the change in RSS.

Methods

In this retrospective study there were 229 ELBW infants with sBPD (78 in the TpF group, 151 in the non-TpF group). SPSS software was used for univariate analyses.

Results

There was no difference in sex or race. TpF group had (i) a lower BW, GA, higher severity of illness (ii) higher incidence of LPHN (p < 0.05), (iii) higher need for GT (p < 0.001) and TT (p < 0.001). In the TpF group, 60 who were on TpF for pulmonary protection from micro aspiration (lung protection group), had significantly improved RSS (p < 0.05), and symptoms within 45 days in 57 out of 60 infants (95%). They improved their respiratory status by 14 days, and 80% of responders could be identified by 21 days after initiation. In the 18 that TpF was started for documented airway protection (airway protection group), there was a higher need for GT or TT.

Conclusions

TpF could play an essential role in the management of ELBW infants with sBPD. Considering the limitations of a single center retrospective study, prospective randomized control trials are needed to confirm these findings.

The role of nutritional interventions in the prevention and treatment of chronic lung disease of prematurity

Chronic lung disease of prematurity or bronchopulmonary dysplasia (BPD) is a common complication of preterm birth. Nutrition may affect incidence and severity of BPD. In this context, the Section on Nutrition, Gastroenterology and Metabolism, the Pulmonary Section of the European Society for Paediatric Research (ESPR) and SPR have joined forces to review the current knowledge on nutritional issues related to BPD. The aim of this narrative review is to discuss the clinical implications for nutritional practice. Nutrient deficiencies may influence pathogenesis of BPD. Adequate nutrition and growth can play a crucial role in the prevention of and recovery from BPD. Optimal nutrition strategy is an important principle, especially in the early postnatal period. As optimal energy intake in infants at risk of BPD or with evolving BPD is not yet defined, further research with well-designed studies on nutritional strategies for preterm infants with BPD is urgently needed. IMPACT: Based on current evidence it seems reasonable to recommend that BPD diagnosed infants should receive an energy supply ranging from 120 to 150 Kcal/kg/d. Exclusive MOM feed with adequate fortification should be encouraged as this is associated with a significant reduction in the risk of BPD. Suboptimal nutritional delivery is often seen in preterm infants with BPD compared to controls.

A clinical consensus paper on jejunal tube feeding in children

BACKGROUND

Feeding problems are common in children with complex medical problems or acute critical illness and enteral nutrition may be required. In certain situations, gastric tube feeding is poorly tolerated or may not be feasible. When feed intolerance persists despite appropriate adjustments to oral and gastric enteral regimens, jejunal tube feeding can be considered as an option for nutrition support.

METHODS

A multidisciplinary expert working group of the Australasian Society of Parenteral and Enteral Nutrition was convened. They identified topic questions and five key areas of jejunal tube feeding in children. Literatures searches were undertaken on Pubmed, Embase, and Medline for all relevant studies, between January 2000 and September 2022 (n = 103). Studies were assessed using National Health and Medical Research Council guidelines to generate statements, which were discussed as a group, followed by voting on statements using a modified Delphi process to determine consensus.

RESULTS

A total of 24 consensus statements were created for five key areas: patient selection, type and selection of feeding tube, complications, clinical use of jejunal tubes, follow-up, and reassessment.

CONCLUSION

Jejunal tube feeding is a safe and effective means of providing nutrition in a select group of pediatric patients with complex medical needs, who are unable to be fed by gastric tube feeding. Appropriate patient selection is important as complications associated with jejunal tube feeding are not uncommon, and although mostly minor, can be significant or require tube reinsertion. All children receiving jejunal tube feeding should have multidisciplinary team assessment and follow-up.

Transpyloric feeding is associated with adverse in-hospital outcomes in infants with severe bronchopulmonary dysplasia

OBJECTIVE

To estimate the association of transpyloric feeding (TPF) with the composite outcome of tracheostomy or death for patients with severe bronchopulmonary dysplasia (sBPD).

STUDY DESIGN

Retrospective multi-center cohort study of preterm infants <32 weeks with sBPD receiving enteral feedings. We compared infants who received TPF at 36, 44, or 50 weeks post-menstrual age to those who did not receive TPF at any of those timepoints. Odds ratios were adjusted for gestational age, small for gestational age, male sex, and invasive ventilation and FiO2 at 36 weeks.

RESULTS

Among 1039 patients, 129 (12%) received TPF. TPF was associated with an increased odds of tracheostomy or death (aOR 3.5, 95% CI 2.0-6.1) and prolonged length of stay or death (aOR 3.1, 95% CI 1.9-5.2).

CONCLUSIONS

Use of TPF in sBPD after 36 weeks was infrequent and associated with worse in-hospital outcomes, even after adjusting for respiratory severity at 36 weeks.

Nutritional Needs of the Infant with Bronchopulmonary Dysplasia

Growth failure is a common problem in infants with established bronchopulmonary dysplasia (BPD). Suboptimal growth for infants with BPD is associated with unfavorable respiratory and neurodevelopmental outcomes; however, high-quality evidence to support best nutritional practices are limited for this vulnerable patient population. Consequently, there exists a wide variation in the provision of nutritional care and monitoring of growth for infants with BPD. Other neonatal populations at risk for growth failure, such as infants with congenital heart disease, have demonstrated improved growth outcomes with the creation and compliance of clinical protocols to guide nutritional management. Developing clinical protocols to guide nutritional management for infants with BPD may similarly improve long-term outcomes. Given the absence of high-quality trials to guide nutritional practice in infants with BPD, the best available evidence of systematic reviews and clinical recommendations can be applied to optimize growth and decrease variation in the care of these infants.

Nutrition-based implications and therapeutics in the development and recovery of bronchopulmonary dysplasia

Premature births account for over 10% of live births worldwide. Bronchopulmonary dysplasia (BPD) represents a severe sequela in neonates born very prematurely and remains the most common chronic neonatal lung disease, often leading to serious adverse consequences in adulthood. Nutrition plays a crucial role in lung development and repair. Ongoing research has primarily focused on the pathogenesis and prevention of BPD in preterm birth. However, infants with established BPD need specialist medical care that persists throughout their hospitalization and continues after discharge. This manuscript aims to highlight the impact of growth and nutrition on BPD and highlight research gaps to provide direction for future studies. Protective practices include ensuring adequate early energy delivery through parenteral nutrition and enteral feedings while carefully monitoring total fluid intake and the use of breast milk over formula. These nutritional strategies remain the same for infants with established BPD with the addition of limiting the use of diuretics and steroids; but if employed, monitoring carefully without compromising total energy delivery. Functional nutrient supplements with a potential protective role against BPD are revisited, despite the limited evidence of their efficacy, including vitamins, trace elements, zinc, lipids, and sphingolipids. Planning post-intensive care and outpatient longitudinal nutrition support is critical in caring for an infant with established BPD.

Gastroesophageal Reflux Treatment in Infancy Through Young Adulthood

Gastroesophageal reflux treatment varies greatly across the pediatric age spectrum. Infant reflux treatments rely heavily on nutritional interventions, whereas reflux in older children is treated more commonly with medications. However, because of the broad differential diagnosis, treatment nonresponse merits a re-evaluation of the diagnosis being treated and additional testing to provide a more precision-medicine approach to care.

A review and guide to nutritional care of the infant with established bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) remains the most common long-term morbidity of premature birth, and the incidence of BPD is not declining despite medical advancements. Infants with BPD are at high risk for postnatal growth failure and are often treated with therapies that suppress growth. Additionally, these infants may display excess weight gain relative to linear growth. Optimal growth and nutrition are needed to promote lung growth and repair, improve long-term pulmonary function, and improve neurodevelopmental outcomes. Linear growth in particular has been associated with favorable outcomes yet can be difficult to achieve in these patients. While there has been a significant clinical and research focus regarding BPD prevention and early preterm nutrition, there is a lack of literature regarding nutritional care of the infant with established BPD. There is even less information regarding how nutritional needs change as BPD evolves from an acute to chronic disease. This article reviews the current literature regarding nutritional challenges, enteral nutrition management, and monitoring for patients with established BPD. Additionally, this article provides a practical framework for interdisciplinary nutritional care based on our clinical experience at the Comprehensive Center for Bronchopulmonary Dysplasia.

Oral Care Associated With Less Microaspiration in Ventilated Cardiac Patients

Aspiration is common in mechanically ventilated patients and may predispose patients to aspiration pneumonia, chemical pneumonitis, and chronic lung damage. Pepsin A is a specific marker of gastric fluid aspiration and is often detected in ventilated pediatric patients. We investigated the effect of oral care and throat suctioning in the detection of pepsin A in tracheal aspirates (TAs) up to 4 hours after these procedures.

Methods

Twelve pediatric patients between age 2 weeks to 14 years who underwent intubation for cardiac surgery were enrolled in this study. Six of the 12 patients were consented before their surgery with initial specimen collected at the time of intubation and last one shortly before extubation (intubation duration < 24 hours). The remaining 6 patients were consented after cardiac surgery. All specimens were collected per routine care per respiratory therapy protocol and shortly before extubation (intubation duration > 24 hours). Tracheal fluid aspirates were collected every 4 to 12 hours in the ventilated patients. Enzymatic assay for gastric pepsin A and protein determination were performed. The time of oral care and throat suctioning within 4 hours prior was recorded prospectively.

Results

A total of 342 TA specimens were obtained from the 12 intubated pediatric patients during their course of hospitalization; 287 (83.9%) showed detectable total pepsin (pepsin A and C) enzyme activity (> 6 ng/mL) and 176 (51.5%) samples had detectable pepsin A enzyme levels (>6 ng/mL of pepsin A). Only 29 samples of 76 samples (38.2%) had evidence of microaspiration after receiving oral care, while 147 of 266 (55.3%) samples were pepsin A positive when no oral care was provided. Odds ratio is 0.50 (Cl 0.30-0.84), and the number needed to treat is 5.8 (Confidence interval 3.4-22.3). Testing air filters for pepsin was not beneficial.

Conclusion

Oral care is a highly effective measure to prevent microaspiration of gastric fluid in ventilated pediatric patients. The number needed to treat (5.8) suggests this is a very effective prevention strategy. Our study suggests that pepsin A is a useful and sensitive biomarker that allows identification of gastric aspiration.

Transpyloric Feeding is Associated With Improved Oxygenation Compared With Gastric Feeding Among Nonintubated Extremely Low Birth Weight Infants

OBJECTIVE

To study the impact of transpyloric (TP) feed initiation on short-term oxygenation and manual oxygen blender titration among extremely low birth weight infants.

STUDY DESIGN

This retrospective study evaluated several measures of oxygenation among extremely low birth weight infants receiving positive pressure respiratory support for 96 hours before and after TP tube placement in a single neonatal intensive care unit during the years 2017- 2020. The measures included the achieved oxygen saturation (SpO₂), the baseline fraction of inspired oxygen (FiO₂), the SpO₂/FiO₂ ratio, the number and severity of hypoxemic episodes and the frequency of manual oxygen titrations (titration index) and were analyzed using an interrupted time series regression approach.

RESULTS

A total of 56 infants were evaluated. No significant differences were observed in any oxygenation measures during TP vs gastric feeding among 14 intubated infants. However, among 42 nonintubated patients, significant improvements were observed in the median SpO₂/FiO₂ ratios (P = .001), median titration index (P = .05), median number of hypoxemic episodes (P = .02), and median severity of hypoxemic episodes (P = .008) after TP tube placement.

CONCLUSIONS

The transition from gastric to TP tube feeding was temporally associated with acute improvement in oxygenation for nonintubated infants, but not for intubated infants.

The Role of Nutrition in the Prevention and Management of Bronchopulmonary Dysplasia: A Literature Review and Clinical Approach

Bronchopulmonary dysplasia (BPD) remains the most common severe complication of preterm birth, and nutrition plays a crucial role in lung growth and repair. A practical nutritional approach for infants at risk of BPD or with established BPD is provided based on a comprehensive literature review. Ideally, infants with BPD should receive a fluid intake of not more than 135-150 mL/kg/day and an energy intake of 120-150 kcal/kg/day. Providing high energy in low volume remains a challenge and is the main cause of growth restriction in these infants. They need a nutritional strategy that encompasses early aggressive parenteral nutrition and the initiation of concentrated feedings of energy and nutrients. The order of priority is fortified mother's own milk, followed by fortified donor milk and preterm enriched formulas. Functional nutrient supplements with a potential protective role against BPD are revisited, despite the limited evidence of their efficacy. Specialized nutritional strategies may be necessary to overcome difficulties common in BPD infants, such as gastroesophageal reflux and poorly coordinated feeding. Planning nutrition support after discharge requires a multidisciplinary approach to deal with multiple potential problems. Regular monitoring based on anthropometry and biochemical markers is needed to guide the nutritional intervention.

Bronchopulmonary Dysplasia: Then, Now, and Next

Bronchopulmonary dysplasia (BPD) has evolved considerably since its first description over 50 years ago. This review aims to provide a historical framework for conceptualizing BPD and a current understanding of the changing definition, epidemiology, pathophysiology, treatment, and outcomes of BPD. The transdisciplinary approach that led to the initial phenotypic description of BPD continues to hold promise today. Investigators are refining the definition of BPD in light of changes in clinical care and increasing survival rates of very preterm infants. Despite improvements in perinatal care the incidence of BPD continues to increase. There is growing recognition that antenatal risk factors play a key role in the development of BPD. Strategies designed to prevent or limit neonatal lung injury continue to evolve. Defining the phenotype of infants with BPD can meaningfully direct treatment. Infants with BPD benefit from an interdisciplinary approach to longitudinal care with a focus on growth and neurocognitive development. While the ultimate impact of BPD on long-term pulmonary morbidity remains an active area of investigation, current data indicate that most children and adolescents with a history of BPD have a quality of life comparable to that of other preterm infants.