Factors associated with postmenstrual age at full oral feeding in very preterm infants

Implementation of Nasogastric Tube Feedings at Discharge in a Large Quaternary NICU: A Literature Review, Proposed Algorithm, and Our Center Experience

The aim of this study is to provide an extensive review of the published literature regarding the use of nasogastric (NG) feeds at discharge in the neonatal population as well as our experience with the implementation of an NG feeds at discharge program in our level IV neonatal intensive care unit.We reviewed and compared the use of NG tubes at discharge and gastrostomy tubes in the neonatal population. We provide an extensive review of previous publications regarding programs of NG feeds at discharge in neonates across the United States and Europe including preterm neonates, neonates with chronic lung disease, and neurological injury. We also reviewed parents' perspectives on NG use at discharge in the neonatal population as well as the use of telehealth in remote monitoring of neonates discharged on NG feeds. We reviewed the economic benefits of such programs. We finally provide our center's algorithm and workflow as well as our center's experience.Twenty-five patients have been discharged so far from this program since its implementation in December 2020. Only 1 patient of the 25 patients discharged on NG tube feeds required gastrostomy tube placement.Discharge with NG tube feeds in a carefully selected population is safe, and feasible and can lead to increased parent satisfaction, besides offering a developmental advantage for the neonates when the only remaining inpatient need is achieving full oral feeds. · Discharge with NG tube feeds in a carefully selected neonatal population is safe and feasible.. · Nasogastric feeds at discharge can lead to increased parent satisfaction and a developmental advantage for the neonates when the only remaining inpatient need is achieving full oral feeds.. · Carefully structured education at discharge, as well as follow-up programs in place can ensure adequate parental support during this process.. · Telehealth can play a key role in implementation of such programs..

Factors associated with feeding problems in bottle-fed preterm infants: A descriptive cross-sectional study

BACKGROUND

The feeding problems of preterm infants often persist after neonatal intensive care unit discharge. Further evidence on the feeding problems preterm infants experience after hospital discharge is needed to better serve this vulnerable population. This study aimed to identify infant-related factors associated with bottle-feeding problems in preterm infants before the age of 7 months.

MATERIALS AND METHODS

This descriptive and cross-sectional study included 338 mothers of preterm infants younger than 7 months of corrected age between April 2023 and April 2024. Mothers completed a survey that included infant and mother information form and Turkish version of the NeoEAT-Bottle-feeding assessment tool.

RESULTS

Very and moderately preterm infants exhibited more problematic feeding symptoms according to NeoEAT-Bottle-feeding total scale and all subscale scores compared with late preterm infants (P < 0.05). Gestational age at birth was negatively correlated with NeoEAT-Bottle-feeding total scores (P = 0.001). Additionally, preterm infants with a diagnosed feeding problem had higher NeoEAT-Bottle-feeding total and subscale scores than those without (P < 0.01). In the multivariate regression analysis, very preterm status and presence of gastroesophageal reflux were predictors of higher NeoEAT-Bottle-feeding total and all subscale scores (P < 0.01), and moderately preterm status was associated with higher NeoEAT-Bottle-feeding total (P = 0.036) and infant regulation subscale scores (P = 0.001).

CONCLUSION

Very preterm and moderate preterm birth, gastroesophageal reflux, and diagnosed feeding disorders were associated with problematic feeding. Identifying preterm infants who have difficulty with bottle feeding can guide primary care interventions or referral to specialists to achieve more favorable long-term outcomes.

Systemizing and Transforming Preterm Oral Feeding Through Innovative Algorithms

Background: Establishing safe and efficient oral feeds for preterm infants is one of the last milestones to be achieved prior to discharge home. However, this process commonly elicits stress and anxiety in both care providers, such as nurses and the entire healthcare team in the Neonatal Intensive Care Unit (NICU), as well as parents. These feelings of uncertainty are exacerbated by the non-linear progression of oral feeding development and the absence of a systematized approach to initiate and advance feedings. Methods: In this 48-bed tertiary perinatal centre, staff surveys and a needs assessment showed dissatisfaction and increasing stress and anxiety due to the inconsistencies in initiating and advancing oral feeds. This paper describes the formation of a multidisciplinary feeding committee which reviewed various oral feeding training materials and the ultimate creation of two innovative oral feeding algorithms and their corresponding education materials. Results: The Sunnybrook Feeding Committee has developed two evidence-based algorithms, one for initiating oral feeds and another for monitoring progress with objective decision-making points during common oral feeding challenges. To complement and support these algorithms, educational materials and a comprehensive documentation process were also created. These resources included detailed instructions, visual aids, and step-by-step guides to help staff understand and apply the algorithms effectively. Additionally, the educational materials aimed to standardize training and ensure consistency across the NICU, further promoting a systematic approach to preterm oral feeding. Implementation of these algorithms also aimed to provide evidence-based, expert-guided guidelines for assessing readiness, initiating feeds, monitoring progress, and making necessary adjustments. Conclusions: This structured approach lays the foundation for a unit-wide language and systematic process for oral feeding. The next steps in this quality improvement project involve educating and piloting the implementation of the developed oral feeding algorithms, gathering staff feedback, and refining the tools accordingly. The goal is to enhance overall care quality, reduce stress for both care providers and parents, and ensure the best possible start for vulnerable preterm infants, ultimately supporting a smooth and successful transition to home.

Transition to competent oral feeding in preterm infants: Analyzing timing and determinants

INTRODUCTION

The achievement of oral feeding competence (OFC) is a challenge in preterm infants and can be affected by several factors.

OBJECTIVE

The aim of our study was to determine the time elapsed to development of OFC in very low birth weight (VLBW, weight <1500g) preterm infants and to identify factors associated with greater difficulty in achieving this skill.

POPULATION AND METHODS

Observational, longitudinal and prospective study in VLBW infants over a period of 7 years (2016-2022). We collected data on perinatal variables, feeding practices and complications associated with prematurity. We analyzed the number of days needed to achieve OFC and which variables predicted greater delay in achieving OFC.

RESULTS

We included 145 VLBW infants with a median gestational age (GA) of 29 weeks with a weight of 1247g. Oral feeding was initiated at 33.6 weeks (SD, 1.2) and full oral feeding was achieved at 35.9 weeks (SD, 1.9). The median time to achievement of OFC was 15 days (8-22.5). The variables associated with longer delay of OFC were severe combined morbidity (24 vs 14 days; P<.001) and moderate/severe bronchopulmonary dysplasia (23 vs 14 days; P<.001). In infants without severe combined morbidity, we found no differences in the days elapsed to achievement of OFC between those born before or after 28 weeks of GA (P=.131).

CONCLUSIONS

Our findings highlight the importance of structuring the transition to oral feeding and identifying the most at-risk group, which in our study were infants with severe morbidity associated with prematurity, for the purpose of targeting potential interventions.

Need for Gastrostomy Tube in Periviable Infants

OBJECTIVE

 We sought to identify clinical and demographic factors associated with gastrostomy tube (g-tube) placement in periviable infants.

STUDY DESIGN

 We conducted a single-center retrospective cohort study of live-born infants between 22 and 25 weeks' gestation. Infants not actively resuscitated and those with congenital anomalies were excluded from analysis.

RESULTS

 Of the 243 infants included, 158 survived until discharge. Of those that survived to discharge, 35 required g-tube prior to discharge. Maternal race/ethnicity (p = 0.006), intraventricular hemorrhage (p = 0.013), periventricular leukomalacia (p = 0.003), bronchopulmonary dysplasia (BPD; p ≤ 0.001), and singleton gestation (p = 0.009) were associated with need for gastrostomy. In a multivariable logistic regression, maternal Black race (Odds Ratio [OR] = 2.88; 95% confidence interval [CI]: 1.11-7.47; p = 0.029), singleton gestation (OR = 3.99; 95% CI: 1.28-12.4; p = 0.017) and BPD (zero g-tube placement in the no BPD arm; p ≤ 0.001) were associated with need for g-tube.

CONCLUSION

 A high percentage of periviable infants surviving until discharge require g-tube at our institution. In this single-center retrospective study, we noted that maternal Black race, singleton gestation, and BPD were associated with increased risk for g-tube placement in infants born between 22 and 25 weeks' gestation. The finding of increased risk with maternal Black race is consistent with previous reports of racial/ethnic disparities in preterm morbidities. Additional studies examining factors associated with successful achievement of oral feedings in preterm infants are necessary and will inform future efforts to advance equity in newborn health.

KEY POINTS

· BPD, singleton birth, and Black race are associated with need for g-tube in periviable infants.. · Severe intraventricular hemorrhage is associated with increased mortality or g-tube placement in periviable infants.. · Further investigation into the relationship between maternal race and g-tube placement is warranted..

Infant massage as a stress management technique for parents of hospitalized extremely preterm infants

Mothers of infants born extremely preterm requiring prolonged medical intervention in the Neonatal Intensive Care Unit (NICU) are at high risk of developing stress. Parent-administered infant massage is a well-established, safe intervention for preterm infants with many developmental benefits, but the published literature has mostly examined its impact on infants and parents through self-reported or observational measures of stress. The aim of this study was to measure salivary cortisol, a biomarker for stress, in extremely preterm infants and their mothers immediately pre and post parent-administered infant massage in order to detect potential changes in physiologic stress. Twenty-two mother-infant dyads completed massage education with a physical or occupational therapist. All dyads provided salivary cortisol samples via buccal swab immediately pre- and post-massage at the second session. Of mothers determined to be "cortisol responders" (15/22), salivary cortisol levels were lower after massage (pre-minus post-level: -26.47 ng/dL, [CI = -4.40, -48.53], p = .016, paired t-test). Our primary findings include a clinically significant decrease (as measured by percent change) in maternal cortisol levels immediately post parent-administered massage, indicating decreased physiological stress. Integration of infant massage into NICU clinical practice may support maternal mental health, but further powered studies are necessary to confirm findings.

Rates and Determinants of Home Nasogastric Tube Feeding in Infants Born Very Preterm

OBJECTIVE

To examine rates and determinants of home nasogastric (NG)-tube feeding at hospital discharge in a cohort of very preterm infants within the Canadian Neonatal Network (CNN).

STUDY DESIGN

This was a population-based cohort study of infants born <33 weeks of gestation and admitted to neonatal intensive care units (NICUs) participating in the CNN between January 1, 2010, and December 31, 2018. We excluded infants who had major congenital anomalies, required gastrostomy-tube, or were discharged to non-CNN facilities. Multivariable logistic regression analysis was used to identify independent determinants of home NG-tube feeding at hospital discharge.

RESULTS

Among the 13 232 infants born very preterm during the study period, 333 (2.5%) were discharged home to receive NG-tube feeding. Rates of home NG-tube feeding varied across Canadian NICUs, from 0% to 12%. Determinants of home NG-tube feeding were gestational age (aOR 0.94 per each gestational week increase, 95% CI 0.88-0.99); duration of mechanical ventilation (aOR 1.02 per each day increase, 95% CI 1.01-1.02); high illness severity at birth (aOR 1.32, 95% CI 1.01-1.74); small for gestational age (aOR 2.06, 95% CI 1.52-2.78); male sex (aOR 0.61, 95% CI 0.49-0.77); severe brain injury (aOR 1.60, 95% CI 1.10-2.32); and bronchopulmonary dysplasia (aOR 2.22, 95% CI 1.67-2.94).

CONCLUSIONS

Rates of home NG-tube feeding varied widely between Canadian NICUs. Higher gestational age and male sex reduced the odds of discharge home to receive NG-tube feeding; and in contrast small for gestational age, severe brain injury, prolonged duration on mechanical ventilation and bronchopulmonary dysplasia increased the odds.

Nutrition and growth in infants with established bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) remains the most common late morbidity of preterm birth. Ongoing clinical care and research have largely focused on the pathogenesis and prevention of BPD in preterm infants. However, preterm infants who develop BPD have significant medical needs that persist throughout their neonatal intensive care unit course and continue post-discharge, including those associated with growth and nutrition. The objective of this manuscript was to provide a review on nutrition and growth in infants with established BPD after discharge from the hospital and to identify the knowledge and research gaps to provide direction for future studies.