The Impact of Physical and Environment Factors on Parental Presence for Oral Feeding in New Zealand Neonatal Intensive Care Units

AIM

To identify physical environmental factors influencing family involvement in feeding in New Zealand neonatal units.

BACKGROUND

Infant oral feeding development is critical for both short-term feeding skills and longer term neurodevelopmental outcomes. The neonatal environment is well-known as challenging for neuroprotection due to negative sensory exposure. The impact of environmental factors on oral feeding in New Zealand (NZ) neonatal units is currently unexplored, and knowledge of this could allow for evidence-based unit design.

METHODS

Focused ethnography at five neonatal units, a national survey of NZ neonatal professionals (n = 102), and five focus groups were carried out. Current oral feeding practice, and beliefs, experiences, and opinions of unit staff and family about these practices were explored. Data were analyzed using qualitative content analysis.

RESULTS

Units were providing the best experience to families that they could with the resources they had available. Lack of physical space, lack of privacy, limited on-site accommodation for families, and lack of coordination between maternity and neonatal services were identified as impacting on family's comfort and sense of homeliness on the unit. Unit staff used furniture, screens, and external accommodation providers to support families where they could.

CONCLUSIONS

The physical design of neonatal units in New Zealand provides barriers to family's spending time privately developing oral feeding. Solutions are proposed to increase the size of bedspaces, provide single-family rooms, create greater on-site family accommodation options, combine maternity and neonatal healthcare, and improve family comfort and therefore connection with their infant.

Effective delivery and selective insecticidal activity of double-stranded RNA via complexation with diblock copolymer varies with polymer block composition

BACKGROUND

Chemical insecticides are an important tool to control damaging pest infestations. However, lack of species specificity, the rise of resistance and the demand for biological alternatives with improved ecotoxicity profiles means that chemicals with new modes of action are required. RNA interference (RNAi)-based strategies using double-stranded RNA (dsRNA) as a species-specific bio-insecticide offer an exquisite solution that addresses these issues. Many species, such as the fruit pest Drosophila suzukii, do not exhibit RNAi when dsRNA is orally administered due to degradation by gut nucleases and slow cellular uptake pathways. Thus, delivery vehicles that protect and deliver dsRNA are highly desirable.

RESULTS

In this work, we demonstrate the complexation of D. suzukii-specific dsRNA for degradation of vha26 mRNA with bespoke diblock copolymers. We study the ex vivo protection of dsRNA against enzymatic degradation by gut enzymes, which demonstrates the efficiency of this system. Flow cytometry then investigates the cellular uptake of Cy3-labelled dsRNA, showing a 10-fold increase in the mean fluorescence intensity of cells treated with polyplexes. The polymer/dsRNA polyplexes induced a significant 87% decrease in the odds of survival of D. suzukii larvae following oral feeding only when formed with a diblock copolymer containing a long neutral block length (1:2 cationic block/neutral block). However, there was no toxicity when fed to the closely related Drosophila melanogaster.

CONCLUSION

We provide evidence that dsRNA complexation with diblock copolymers is a promising strategy for RNAi-based species-specific pest control, but optimisation of polymer composition is essential for RNAi success. © 2023 The Authors. Pest Management Science published by John Wiley & Sons Ltd on behalf of Society of Chemical Industry.

Effects of a valved infant-bottle with ergonomic teat on the coordination of sucking, swallowing, and respiration in late-preterm infants. The Safe Oral Feeding randomized Trial

Introduction

Breastfeeding naturally enables the coordination of sucking, swallowing, and respiration patterns for safe feeding. When breastfeeding is not possible a feeding device that releases milk in response to intra-oral vacuum could potentially offer improved coordination of sucking, swallowing, and breathing patterns compared to conventional devices. The aim of the study is to evaluate the effect of a valved infant-bottle with an ergonomic teat compared to a standard infant-bottle.

Methods

This unblinded randomized controlled trial focused on late preterm infants fed by bottle for at least three meals over the day, admitted to the Neonatal Unit of Sant'Anna Hospital (Turin, Italy). Infants were randomized to be fed with a valved infant-bottle with an ergonomic teat (B-EXP arm) or with a standard infant-bottle (B-STD arm). Monitoring included a simultaneous synchronized recording of sucking, swallowing and respiration. The main outcome was the swallowing/breathing ratio.

Results

Forty infants (20 B-EXP arm; 20 B-STD arm) with a median gestational age of 35.0 weeks (IQR 35.0-36.0 weeks) completed the study. Four infants were censored for the presence of artifacts in the polygraphic traces. The median swallowing/breathing ratio was 1.11 (1.03-1.23) in the B-EXP arm and 1.75 (1.21-2.06) in the B-STD (p = .003). A lower frequency of swallowing events during the inspiratory phase of breathing was observed in B-EXP arm compared with B-STD arm (p = 0.013).

Discussion

The valved infant-bottle with an ergonomic teat improves the coordination of sucking-swallowing-respiration and limits the risk of inhalation reducing the frequency of swallowing during the inspiratory phase.

[Early oral feeding does not pose a risk after upper gastrointestinal surgeries]

Bevezetés: A malignus megbetegedésekben szenvedő páciensek prehabilitációjának és rehabilitációjának kiemelkedően fontos eleme a tápláltság és a fizikai állapot felmérése és nyomon követése. Az ERAS- (Enhanced Recovery After Surgery) protokoll fontos része a posztoperatív korai, szájon keresztüli táplálás megkezdése. Az e táplálási metódusnak a felső gastrointestinalis traktus műtétei utáni alkalmazására vonatkozó adatok hiányosak. Célkitűzés: Annak igazolására, hogy a korai, szájon át történő táplálás nem jelent hátrányt ebben a betegcsoportban, a Pécsi Tudományegyetem Sebészeti Klinikáján a 2020 februárja és 2022 júliusa között ilyen módon táplált betegek adatait vetettük össze egy becsült részvételi valószínűség szerinti párosítási tanulmány során, a klasszikus módon kezelt betegek adataival. Módszer: Vizsgálatunkba olyan betegeket vontunk be, akik felső gastrointestinalis daganat miatti műtéten estek át, melynek során nyelőcsővel képzett anastomosis került kialakításra (teljes gastrectomiák és nyelőcső-resecciók). A tanulmány 50 beteget foglalt magában: 25 beteget a korai oralis táplálási csoportba, míg 25 beteget a hagyományos oralis táplálásban részesülő csoportba soroltunk. Eredmények: Az oralis táplálás átlagosan a korai táplálási csoportban a műtét utáni 2,09. napon, míg a késői táplálási csoportban az 5,52. napon kezdődött. A korai csoportban a posztoperatív kórházi tartózkodási idő átlagosan 8,875 nap volt, szemben a késői csoportban jegyzett 12,161 napos átlaggal (p<0,05). Ugyanakkor nem volt kimutatható különbség a mortalitási rátában, illetve az anastomosissal összefüggő szövődmények előfordulásában. Megbeszélés: Megállapítható, hogy a korai, szájon keresztüli táplálási csoportban statisztikailag szignifikáns csökkenés mutatható ki a bélműködés megindulásáig eltelt időben, a kórházi tartózkodási időt tekintve és a posztoperatív parenteralis táplálás időtartamában. Következtetés: Elmondható, hogy a korai, szájon keresztüli táplálás alkalmazása a felső gastrointestinalis traktus műtétei után is biztonságos. Orv Hetil. 2024; 165(1): 24–29.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Effect of Breast Milk Odor on Feeding Cues, Transition Time to Oral Feeding, and Abdominal Perfusion in Premature Newborns: A Randomised Controlled Trial

PURPOSE

The present study was conducted to determine the effect of odor stimulation with breast milk (BM) applied to premature newborns before and during enteral feeding on feeding cues, transition time to oral feeding and abdominal perfusion.

DESIGN

This study was a parallel group pretest-post test randomised controlled trial (RCT).

METHODS

The study was conducted in the neonatal intensive care unit (NICU) in Türkiye. Study data were collected from 32 premature newborns between October 2020 and December 2021. Newborns were randomly assigned to either intervention (n = 16) or control (n = 16) groups. Odor stimulation with BM was applied to newborns in the intervention group (IG) before and during enteral feeding for 3 days. Data were collected with the Newborn Information Form, Abdominal Perfusion Follow-up Form, and Feeding Cues Follow-up Form. Yates corrected and Fisher chi-squared test, Mann-Whitney U test, Cohen Kappa statistics, Permanova analysis, and Wilcoxon test were used in the analysis. The study was registered in ClinicalTrials.gov (NCT04843293).

RESULTS

The frequency of feeding cues in newborns who were exposed to the odor of BM, was higher than in the control group (CG) (p < .05). The transition times to oral feeding were similar in newborns in the IG and CG (p > .05). Abdominal perfusion level of newborns in the IG was higher than the CG (p < .05), and the level of abdominal perfusion showed a significant difference in terms of group*time interaction (p < .05).

CONCLUSION

Our findings suggest that odor stimulation with BM will be beneficial in improving the digestive functions of premature newborns.

Factors influencing the decision to introduce alternative nutrition in patients with Duchenne muscular dystrophy

INTRODUCTION/AIMS

Nutritional management of adults with Duchenne muscular dystrophy (DMD) is an important clinical issue. However, it is not clear which dysphagia-related factors should prompt introduction of alternative nutrition (AN). We aimed to determine which patients with DMD were introduced to AN.

METHODS

This retrospective study included 56 patients with DMD (median age, 23.5 years). They were divided into patients able to continue oral feeding (OF) and those introduced to AN. Body weight, frequency of ventilator use, daily meals, history of steroid treatment, results of videofluoroscopic examination of swallowing (VF), and awareness of dysphagia were evaluated.

RESULTS

Of 56 patients, 19 were in the AN group. After AN introduction, 93% of the patients continued oral intake. The proportion of patients who consumed chopped and liquid diets was higher, and body weight was lower, in the AN than in the OF group. There were no significant differences in age, upper limb function of feeding, frequency of ventilator use, or history of steroid therapy between the two groups. The frequencies of aspiration and residue in the pyriform sinus in VF were higher in the AN group than in the OF group. Decision-tree analysis showed that food form and subjective difficulty swallowing solid foods were the most important factors affecting the decision-making for AN.

DISCUSSION

Patients with DMD who had difficulty eating solid foods were started on AN because they were unable to maintain their weight. These findings provide information for future longitudinal studies to assess the value of AN.

Supporting Breastfeeding in Complex Pediatric Otolaryngology Dyads: Clinical Pathway With Illustrative Case Series

OBJECTIVES

The benefits of breastfeeding are well established, yet complex infants are less frequently supported to feed direct or pumped breastmilk. This article aims to provide an algorithm to support complex infants in meeting breastfeeding goals.

METHODS

Two cases are presented to illustrate the breastfeeding support pathway. Each involves early identification of motivated caregivers, consultation of allied health, and assessment of swallowing safety with modification of position or route as appropriate.

RESULTS

Two infants presented herein successfully continued to receive breastmilk despite airway complexity-1 with oral aversion secondary to prolonged nil per os period in the setting of tracheoesophageal fistula, and 1 with a tracheostomy secondary to subglottic stenosis.

CONCLUSIONS

It is both possible and imperative to support complex infants in continuing to breastfeed, either directly or via the safest possible route, for the benefits to both members of the dyad.

Improving feeding skills and transition to breastfeeding in early preterm infants: a randomized controlled trial of oromotor intervention

Introduction

Oromotor therapy exercises used for preterm infants in the NICU might promote oral-motor skills and shorten discharge day. This study investigates the impact of an oral-motor therapy program on the successful transition to breastfeeding (BF) and the enhancement of feeding skills in preterm infants below 30 weeks of gestational age who experience feeding intolerance.

Methods

The intervention group received oral-motor therapy programme for one month, while the control group did not. The feeding skills were evaluated by Early Feeding Skills Assessment Tool (EFS) and Preterm Oral Feeding Readiness Scales (POFRAS).

Results

There was a significant difference in EFS and POFRAS scores, transition to bottle feeding at discharge and transition to BF after discharge between babies given oral-motor therapy programme and controls (p < 0.05). While the transition time to full enteral feeds did not vary significantly between the groups, noteworthy outcomes were observed in the intervention group, including differences in feeding type at discharge, the nature of feeds at discharge, and the success of transitioning to breastfeeding after discharge.

Discussion

We conclude that the oromotor therapy exercises in NICU improves the quality of sucking, contributes to better oromotor skills and promotes transition to enteral feeding and BF in preterm babies.

Clinical Trial Registration

ClinicalTrials.gov, identifier (NCT05845684).

A Survey of Feeding Practices During High-Flow Nasal Cannula Oxygen Therapy

BACKGROUND

High-flow nasal cannula (HFNC) oxygen therapy is used to deliver warm and humidified gases to patients in respiratory failure. A purported advantage of HFNC oxygen therapy is that it can allow for oral feeding while on the device, although few data support this practice. The purpose of this study was to identify practices and opinions with regard to feeding practices during HFNC oxygen therapy.

METHODS

A survey related to the practice and opinions of feeding practices during HFNC oxygen therapy was developed and sent to respiratory therapists, speech-language pathologists, physicians, advanced practice providers, and registered dietitians.

RESULTS

Respondents included 307 professionals from 14 different countries. Most respondents worked in an academic/teaching hospital (n = 174 [56.7%]) with patients ages ≥ 18 years (n = 282 [91.9%]). Most respondents stated that their institution did not have a specific feeding protocol for HFNC oxygen therapy (n = 246 [80.4%]) and felt that patients could have an oral diet during HFNC oxygen therapy if not in imminent danger of being intubated (n = 264 [86.3%]). Fewer than half of the respondents felt that patients should have a bedside/clinical swallow examination before eating and/or drinking during HFNC oxygen therapy (n = 143 [46.7%]). By profession, most physicians/advanced practice providers (n = 67 [59.3%]), respiratory therapists (n = 37 [62.7%]) and half of the registered dietitians (n = 16 [50%]) felt that bedside/clinical swallow examinations were unnecessary before eating and/or drinking with HFNC, but speech-language pathologists were in favor (n = 77 [75.5%]).

CONCLUSIONS

Most facilities did not have a protocol to guide feeding practices when HFNC oxygen therapy is used. Most clinicians felt that an oral diet is safe for stable patients not in danger of being intubated. In general, speech-language pathologists felt that patients on HFNC oxygen therapy should undergo a bedside/clinical swallow examination before eating and/or drinking.

Quantitative non-nutritive sucking measurement as a predictor of oral feeding readiness in newborns

Background and purpose

The purpose of this study is to examine the relationship between the parameters of a silver nanowire-based flexible pressure sensor developed to measure the non-nutritive sucking (NNS) performance and predict the nutritive sucking status in preterm infants.

Methods

Preterm infants who were referred for feeding difficulty during the transition period from tubal feeding to oral feeding were enrolled in our study. A flexible pressure sensor was used to measure the non-nutritive sucking parameters of neonates. The evaluator stimulated the infants' lips and tongue with a pacifier integrated with a sucking pressure sensor, to check whether non-nutritive sucking had occurred. When the sucking reflex was induced, it was measured. The infants' sucking characteristics were subdivided into classifications according to the NOMAS criteria and full oral feeding (FOF) status. Quantitative NNS measurement according to the feeding state was compared between groups.

Results

When comparing the quantitative NNS measurement by feeding characteristics, the average sucking pressure was significantly higher in infants in the FOF capable group than those in the incomplete FOF group. In addition, the maximum and average sucking pressure was significantly higher in infants with a normal sucking pattern compared to those with a disorganized sucking pattern. The average NNS pressure was divided over the range of 0-3 kPa and the same weight was assigned to each item. When the optimal cut-off value for the sensitivity and specificity of the average NNS pressure to estimate the FOF was set, a pressure of 1.5 kPa yielded the highest sensitivity (84.62%) and specificity (67.65%) on the receiver operating characteristic (ROC) curve. The area under the curve (AUC) was 0.786, and this result was statistically significant.

Conclusions

This study presents a quantitative parameter for non-nutritive sucking in preterm infants with the use of a flexible pressure sensor. Results show possible quantitative indicators that can aid in predicting when preterm infants can transition to oral feeding and their prognosis. This will serve as a basis for future research on determining the feeding transition period of newborns with health conditions that affect oral feeding.

The effect of oral refeeding compared with nasogastric refeeding on the quality of care for patients hospitalised with an eating disorder: A systematic review

AIM

The aim of this systematic review was to compare the benefits and harms of nasogastric and oral-based refeeding on the quality of care, including effectiveness, safety, and patient experience, for patients hospitalised with an eating disorder.

METHODS

A systematic search for studies measuring comparative data between nasogastric and oral refeeding methods was conducted in August 2021. Title and abstracts and remaining full texts were screened by both authors. Risk of bias was evaluated using the PEDro scale, and overall quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation narrative synthesis.

RESULTS

Seven studies (one randomised controlled trial, five non-randomised studies of interventions, and one qualitative study) with 917 participants were included. There was low certainty evidence that nasogastric refeeding resulted in no difference or a small increase in weekly weight gain, and moderate certainty of greater total weight gain, and very low certainty of increased length of stay compared to oral refeeding. There was no difference or a small increase in discharge weight and body mass index with nasogastric refeeding compared to oral refeeding. No serious adverse events were reported.

CONCLUSION

Patients selected for nasogastric refeeding have a longer duration of illness and lower admission weight, making it difficult to determine which refeeding approach is superior. However, the lack of clear difference in weekly weight gain and the lack of reported harms suggests that other factors such as the normalisation of eating behaviour may be taken into account when choosing the most appropriate refeeding method.

Impact of the Covid-19 Pandemic on Breastfeeding Establishment in Preterm Infants: An Exploratory Study

Purpose: To evaluate breastfeeding outcomes in preterm infants born during the Covid-19 pandemic. Design: An observational cohort study of 33 infants born ≤34 weeks' gestation was conducted. Sample: The study sample consisted of 33 infants divided into 2 groups: infants born during the Covid-19 pandemic (Covid group, n = 11) and those born prior to the pandemic (pre-Covid group, n = 22). Main Outcome Variable: Breastfeeding at hospital discharge. Results: Fewer infants in the Covid group received breastfeeds at full oral feed (p = .015) and none breastfeeding at hospital discharge (p = .001). In addition, fewer infants in the Covid group received non nutritive sucking (p = .612) and more infants in the Covid group required milk supplementation (p = .032). Study results suggest that breastfeeding establishment at hospital discharge in preterm infants is significantly impacted by the Covid-19 pandemic. There is a critical need, in low-risk disease transmission areas, to enhance parental access and to increase in-hospital lactation supports to help safeguard breastfeeding outcomes in preterm infants.

Relationship Between Feeding to Sleep During Infancy and Subsequent Childhood Disease Burden

OBJECTIVE

To investigate the association of feeding to sleep during infancy and subsequent childhood health burdens.

STUDY DESIGN

Information was collected from the parents of children who participated in the national health screening survey when the child was 9-12 months old. The exposure group included participants who were fed to sleep. The primary outcome was all-cause hospital admission (inpatient care, intensive care unit [ICU] admission, or general anesthesia) after age 24 months. Secondary outcomes were subsequent childhood diseases (ie, adenoidectomy and/or tonsillectomy, nasal polyps, allergic rhinitis, acute otitis media, asthma, pneumonia, and aspiration pneumonia), and growth status, as measured by weight-to-age and height-to-age z-scores.

RESULTS

The study cohort consisted of 224 075 children who participated in the health screening program, 29 392 of whom (13.1%; 51% males) were fed to sleep. Exposure was associated with an increased risk of all-cause hospitalization after age 24 months (hazard ratio [HR], 1.05; 95% CI, 1.03-1.07), but not with admission to an ICU or receipt of general anesthesia. This also was related to adenoidectomy and/or tonsillectomy (HR, 1.08; 95% CI, 1.01-1.15), dental caries (HR, 1.32; 95% CI, 1.23-1.40), asthma (HR, 1.14; 95% CI, 1.14-1.24), pneumonia (HR, 1.10; 95% CI, 1.07-1.13), overweight (HR, 1.06; 95% CI, 1.03-1.09), and obesity (HR, 1.11; 95% CI, 1.06-1.16).

CONCLUSIONS

Several adverse health outcomes are related to feeding to sleep during early childhood.

Parents' experiences of their child's transition from tube to oral feeding during an intensive intervention programme

BACKGROUND

Persistent enteral tube feeding beyond the point of medical and/or physical necessity provides important nutrition to a child but may have implications for their development, gastrointestinal tract and quality of life. Tube dependency can affect parent-child relationships and sibling and family dynamics and place additional medical demands upon parents. It is therefore important to transition children from tube to oral eating and drinking as soon as is medically safe to do so. Tube weaning requires a skilled team to support the transition to oral intake; however, access to experienced teams is inconsistent. Without transparent discussions with their treating teams, many parents are left to navigate tube weaning options independently.

METHODS

Fourteen parents were interviewed using semi-structured interviews. We explored the experiences of parents across their child's progression towards oral feeding, from the decision-making process to undertaking an intensive multi-disciplinary tube weaning programme. Thematic analysis of the parents' stories shaped the development of seven themes.

RESULTS

Parents were unaware that tube weaning would be required and how that would be facilitated. They expressed a strong belief that their child could learn to eat-if afforded an opportunity. Furthermore, parents are prepared to disengage from current services if they feel they are not respected members of their child's therapeutic team. Three key learnings were identified relating to the need for tube exit plans, parents as key team members and parents as change agents.

CONCLUSIONS

Parenting a tube-fed child, initiating and engaging in tube weaning, is a stressful and emotional journey. However, by establishing care partnerships, parents are willing to put trust in a process if provided with options and afforded autonomy, empowerment, acknowledgement and relevant support.

Predictive ability of postnatal growth failure for adverse feeding-related outcomes in preterm infants: an exploratory study comparing Fenton with INTERGROWTH-21st preterm growth charts

BACKGROUND

Postnatal growth failure (PGF) can impact the short- and long-term health outcomes in preterm infants. However, PGF rates vary according to the way it is defined and the growth chart used to monitor the postnatal growth. Fenton-2013 growth charts which suggest following intrauterine fetal growth compared to INTERGROWTH-21st, one specifically constructed for monitoring preterm extrauterine growth.

OBJECTIVE

Exploratory study to determine the PGF definition at first per oral (PO) that is most predictive of adverse oral feeding-related outcomes in preterm infants.

METHODS

Prospectively collected data of preterm infants 24-32 weeks gestation, who were started on cue-based oral feeds at ≤34 weeks gestation were reviewed. Anthropometric data at first PO (weight, length, and head circumference) were compared according to Fenton and INTERGROWTH-21st growth charts. PGF was defined either as <10th percentile, Z-score change (ZSC) of ≥-1.5 from birth, or ZSC of ≥-2.0. Top-quartile (Q4) of feeding-related outcomes (days from first PO to full PO, post-menstrual age at full PO, days from first PO to discharge, and length of hospital stay) was considered as adverse outcome.

RESULTS

Of the 125 infants included, the median birth gestation and weight were 29.4 weeks and 1235 g, respectively. Incidence of appropriate, small, and large for gestational age was similar at birth by both growth charts. ZSC -1.5 for weight by Fenton was significantly higher at first PO vs. INTERGROWTH-21st (p=.02), while percentile <10th and ZSC -2.0 rates were similar. The PGF definition based on individual anthropometrics at first PO that has the best area under the curve (AUC) for adverse feeding-related outcomes was used to create a combined PGF definition for each growth chart. The AUC for the combined PGF for the Fenton and INTERGROWTH-21st was similar (p>.05) and both have moderate sensitivity and negative predictive value, but have low specificity, positive predictive value, and positive likelihood ratio for adverse feeding-related outcomes.

CONCLUSIONS

The tested definitions of PGF at first PO have only small to moderate predictive ability for adverse feeding-related outcomes in preterm infants.

Investigating the Developmental Trajectory of Long-term Oral Feeding Problems in 'Healthy' Preterm Infants

PURPOSE

To investigate the occurrence of oral feeding problems in preterm infants up to one year after hospital discharge.

METHODS

Thirty-six infants born <34 weeks gestation were enrolled in a prospective exploratory longitudinal pilot study prior to hospital discharge. Parents of eligible infants completed telephone questionnaires at 3, 6, and 12 months corrected gestational age. The occurrence and type of feeding problems; medical problems; and rehabilitation services received were collected.

RESULTS

A total of 26 (72.2%) parents responded, with 11 (42%) identifying feeding problems that developed within the first year of life. Avoidant behavior (including crying, agitated/fussy, and refusing to eat) was the most common feeding problem that occurred.

CONCLUSION

Feeding problems in 'healthy' preterm infants may occur at any point in development within the first year of life. Increased screening after hospitalization is needed for early identification and to make appropriate referrals in a timely manner to prevent and/or reduce the severity of long-term feeding problems.

Advantages of side-lying position. A comparative study of positioning during bottle-feeding in preterm infants (≤34 weeks GA)

BACKGROUND

The quality and safety of bottle-feeding in premature infants can be improved by optimal positioning. This study analysed the advantages of side-lying position (SLP) and semielevated position (SEP) during bottle-feeding in premature infants.

MATERIAL AND METHODS

A total of 42 neonates (n=42) born ≤34 weeks of gestational age were included in the study. Four feeding sessions-two in SLP and two in SEP- were analysed for each newborn. The level of saturation (SpO₂) and heart rate, which are the parameters assessing the physiological stability, were measured in the studied newborns. The other factors that were examined to determine the quality of feeding included the total time of decline of SpO₂ to ≤85%, level of the newborn's alertness measured using the Neonatal Behavioral Assessment Scale, and the frequency of choking episodes. The proportion of milk consumed (volume of milk consumed relative to the volume expected) and the feeding duration as well as the total time of feeding session were recorded.

RESULTS

SLP was safer in terms of the frequency of choking episodes. Choking episodes were more frequently observed with feeding in SEP (p<0.001). Moreover, the proportion of milk consumed by infants was statistically significantly higher in SLP (p<0.046) compared to SEP. No significant differences in the other tested parameters were noted in infants fed in SLP and infants fed in SEP.

CONCLUSIONS

This study demonstrated that SLP is effective in reducing the number of choking episodes during feeding. The proportion of milk consumed was better when the neonates were fed in SLP.

Spinosyns Delivered in Sugar Meals to Aedes aegypti and Aedes albopictus (Diptera: Culicidae): Acute Toxicity and Subacute Effects on Survival, Fecundity, and Fertility

Sugar is an essential source of nutrition for adult mosquitoes to acquire energy. Toxic sugar bait (TSB) provides a promising method for mosquito control by incorporating toxins into artificial sources of sugar (i.e., toxic baits) presented to wild populations. Spinosyns comprise a family of bacterial secondary metabolites with a unique mode of action against the insect nervous system, an appealing environmental safety profile, and potential for incorporation into sugar baits. This research evaluated acute and subacute effects of spinosad (spinosyns A and D) and spinetoram (spinosyns J and L) in sugar meals on survival, fecundity, and fertility of Aedes aegypti and Aedes albopictus. Acute toxicity of spinosyns doubled from 24 to 48 h of assessment, revealing a relatively slow and cumulative action of the formulated spinosyns. Median lethal concentrations at 48 h were lower for spinetoram than for spinosad, lower for Ae. albopictus than Ae. aegypti, and lower for males than females. When exposed to subacute LC50 concentrations of spinosad and spinetoram for 24 h, survival of males and females of both species was diminished compared with controls, fecundity of females was increased, but fertility as measured by hatch rate of eggs was decreased. The formulations may have increased the nutritive value of the sugar meals thereby boosting fecundity, while toxifying embryos, reducing fertility. The inclusion of subacute effects of spinosyns allows assessment of the broader consequences of TSB for adult mosquito control.

The Impact of Infant and Maternal Factors on Oral Feeding Performance in Premature Infants

Aims: To identify infant and maternal factors associated with attainment of full oral feeding (FOF) in premature infants.Method: A retrospective study was performed on 89 premature infants (<34 weeks gestational age) from a tertiary care neonatal intensive care unit (NICU). Infant and maternal factors were concurrently assessed. Infant factors included gestational age, birthweight, continuous positive airway pressure assistance, mechanical ventilation support, and presence of neonatal morbidities including bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), and intraventricular hemorrhages (IVH). Maternal factors included maternal age, first born, twin birth, and presence of mental health conditions including anxiety, stress, or depression.Results: A total of 89 premature infants were included in the sample. A stepwise linear regression model revealed that infants who received mechanical ventilator support and presence of maternal mental health conditions were significantly associated with time to attain FOF.Conclusions: Results suggest that oral feeding performance is influenced not only by infant's medical severity denoted by need for ventilator assistance, but also by presence of maternal anxiety, stress, and/or depression.

Effects of potential probiotic strains LBKV-3 on Immune Cells responses in Malnutrite children: a double-blind, randomized, Controlled trial

This study investigated the phagocytic cell response in malnourished children after oral feeding of a fermented product containing clinically proven probiotic strains of Lactobacillus acidophilus, LBKV-3. The bacterial strain is used as a probiotic for humans to test its effect on immune cell activity in undernourished children below 8 years of age. To study the immune cell activity, implantation abilities of the culture in the GI tract of malnourished children, forty-five children of 6-7 and 7-8 years were randomly selected and distributed in three groups, each comprising 15 children in each of the age group. The test group of the children was receiving 100 g product volunteers/day of freshly prepared probiotic acidophilus milk containing 10⁷ cfu/g of culture. The control group was receiving 100 g freshly prepared "dahi" containing 10⁷ cfu/g of the LAB while the blank group of the volunteers was receiving thermal processed (85° C/30 min) buffalo milk containing 5% fat and 10% SNF at the rate of 100 ml/day/volunteer. Feeding trial was continued for 12 weeks. Blood samples were collected at W2, W4, W8, and W12. The blood serum samples were analyzed for monocytes, neutrophils, basophils, and lymphocytes by BC-3000 + Auto Hematology Analyzer. In conclusion, consumption of PAM increased the proportion of immune cells, including monocytes, neutrophils, basophils, and lymphocytes, as well as their phagocytic activity in all age groups but proportion was significant in the test group of 7-8 years. The effects were higher during W12 compared to W2, W4, and W8, which suggest regulation of the immune system.

Effect of Early Peripheral Parenteral Nutrition Support in an Enhanced Recovery Program for Colorectal Cancer Surgery: A Randomized Open Trial

BACKGROUND

Peripheral parenteral nutrition allows repletion of acute nutrient deficiencies and could prevent further nutrition deficits before and after colorectal surgery. A randomized open study was performed to evaluate the effect of perioperative peripheral parenteral nutrition (PPN) support on postoperative morbidity after colorectal cancer surgery within an enhanced recovery program.

METHODS

Patients were randomized into two groups: peripheral parenteral nutrition (PPN) (with Peri-Olimel N4-E) versus conventional fluid therapy (FT). Ninety-day postoperative complications, laboratory parameters, length of hospital stay, and compliance with the ERAS protocol were assessed.

RESULTS

A total of 158 patients were analysed. The overall 90-day complication rate was 38.6% (61 patients), and 24 patients had major complications (Clavien-Dindo III-V) (15.2%). In the multivariate analysis, the intervention (PPN vs. FC) showed a protective effect against postoperative complications (p = 0.0031, OR = 0.2 (CI: 0.08-0.87)). Following ordinal regression, PPN and early oral tolerance showed a protective effect, being less likely to develop complications or to move from minor to major complications. In patients with low compliance to ERAS during the first postoperative day, PPN showed a protective effect, preventing 28% of morbidity.

CONCLUSIONS

Perioperative peripheral parenteral nutrition (PPN) support with Peri-Olimel N4-E in colorectal cancer surgery associated with early oral intake could reduce postoperative complications.

Nasal respiratory support and tachypnea and oral feeding in full-term newborn lambs

Newborn infants with respiratory difficulties frequently require nasal respiratory support such as nasal continuous positive airway pressure (nCPAP) or high-flow nasal cannulae (HFNC). Oral feeding of these infants under nasal respiratory support remains controversial out of fear of aspiration and cardiorespiratory events. The main objective of this study was to evaluate the safety of oral feeding under different types of nasal respiratory support in newborn lambs without or with tachypnea. Eight lambs aged 4-5 days were instrumented to record sucking, swallowing, respiration, ECG, oxygen saturation, and arterial blood gases. Each lamb was given two bottles of 30 mL of milk with a pause of 30 s under videofluoroscopy in four conditions [no respiratory support, nCPAP 6 cmH₂O, HFNC 7 L/min, HFNC_CPAP (= HFNC 7 L/min + CPAP 6 cmH₂O)] administered in random order. The study was conducted in random order over 2 days, with or without standardized tachypnea induced by thoracic compression with a blood pressure cuff. Generalized linear mixed models were used to compare the four nasal respiratory supports in terms of safety (cardiorespiratory events and aspiration), sucking-swallowing-breathing coordination, and efficacy of oral feeding. Results reveal that no nasal respiratory support impaired the safety of oral feeding. Most of the few laryngeal penetrations we observed occurred with HFNC_CPAP. Nasal CPAP modified sucking-swallowing-breathing coordination, whereas the efficiency of oral feeding decreased under HFNC_CPAP. Results were similar with or without tachypnea. In conclusion, oral feeding under nasal respiratory support is generally safe in a term lamb, even with tachypnea.NEW & NOTEWORTHY The practice of orally feeding newborns suffering from respiratory problems while on nCPAP or HFNC remains controversial for fear of triggering cardiorespiratory events or aspiration pneumonia, or aggravating chronic lung disease. The present results show that bottle-feeding is generally safe in full-term lambs under nasal respiratory support, both without and with tachypnea.

Incidence and risk factors of oral feeding intolerance in acute pancreatitis: Results from an international, multicenter, prospective cohort study

Background

Inability to advance to an oral diet, or oral feeding intolerance, is a common complication in patients with acute pancreatitis associated with worse clinical outcomes. The factors related to oral feeding intolerance are not well studied.

Objective

We aimed to determine the incidence and risk factors of oral feeding intolerance in acute pancreatitis.

Methods

Patients were prospectively enrolled in the Acute Pancreatitis Patient Registry to Examine Novel Therapies in Clinical Experience, an international acute pancreatitis registry, between 2015 and 2018. Oral feeding intolerance was defined as worsening abdominal pain and/or vomiting after resumption of oral diet. The timing of the initial feeding attempt was stratified based on the day of hospitalization. Multivariable logistic regression was performed to assess for independent risk factors/predictors of oral feeding intolerance.

Results

Of 1233 acute pancreatitis patients included in the study, 160 (13%) experienced oral feeding intolerance. The incidence of oral feeding intolerance was similar irrespective of the timing of the initial feeding attempt relative to hospital admission day (p = 0.41). Patients with oral feeding intolerance were more likely to be younger (45 vs. 50 years of age), men (61% vs. 49%), and active alcohol users (44% vs. 36%). They also had higher blood urea nitrogen (20 vs. 15 mg/dl; p < 0.001) and hematocrit levels (41.7% vs. 40.5%; p = 0.017) on admission; were more likely to have a nonbiliary acute pancreatitis etiology (69% vs. 51%), systemic inflammatory response syndrome of 2 or greater on admission (49% vs. 35%) and at 48 h (50% vs. 26%), develop pancreatic necrosis (29% vs. 13%), moderate to severe acute pancreatitis (41% vs. 24%), and have a longer hospital stay (10 vs. 6 days; all p < 0.04). The adjusted analysis showed that systemic inflammatory response syndrome of 2 or greater at 48 h (odds ratio 3.10; 95% confidence interval 1.83–5.25) and a nonbiliary acute pancreatitis etiology (odds ratio 1.65; 95% confidence interval 1.01–2.69) were independent risk factors for oral feeding intolerance.

Conclusion

Oral feeding intolerance occurs in 13% of acute pancreatitis patients and is independently associated with systemic inflammatory response syndrome at 48 h and a nonbiliary etiology.

Current knowledge on this subject

Oral feeding intolerance is a relatively common complication of acute pancreatitis.

Oral feeding intolerance results in longer hospitalization and frequent readmissions.

What is new in this study

The incidence of oral feeding intolerance is similar irrespective of the timing of the initial feeding attempt.

Oral feeding intolerance is independently associated with systemic inflammatory response syndrome at 48 h and nonbiliary etiology.

Early versus late oral feeding following total (pharyngo)laryngectomy: Systematic review and meta-analysis

Timing of oral feeding following total laryngectomy is a contentious issue with highly varied practices. Multiple database search was performed to identify studies comparing outcomes of early (≤5 days) versus late (>5 days) oral feeding. Bias assessment was carried out using Cochrane bias tool. Random-effects meta-analysis was used. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The rate of pharyngocutaneous fistula (PCF) in randomized control trials (RCTs) in early versus late feeding was 15.2% versus 11.7% (RR 1.35, 95%CI [0.68-2.7], p = 0.40). The rate of PCF in the cohort studies was 14.1% versus 20.5% (RR 1.0, 95%CI [0.76-1.3], p = 0.98). The length of hospital stay was significantly shorter in the early feeding group (mean difference (days) -4.68 (-6.2 to -3.1, p < 0.0001). Early oral feeding appears to be safe and is associated with shorter hospital stay. However, the quality of evidence is low and the patient characteristics are not representative of current practices.

RNAi-mediated mortality in southern green stinkbug Nezara viridula by oral delivery of dsRNA

BACKGROUND

The southern green stinkbug, Nezara viridula (Hemiptera: Pentatomidae), is an important emerging polyphagous pest infesting soybean in the United States, Brazil and Argentina. The indiscriminate use of synthetic insecticides to control stinkbugs has limited the effectiveness of current management strategies. Alternatively, RNA interference (RNAi) has emerged as a novel mode of action to control pests in an eco-friendly manner.

RESULTS

Here, we assessed the potential of RNAi technology by oral delivery of double-stranded RNA (dsRNA) for the control of N. viridula. Initially, ten candidate genes were tested by microinjection assay to select the best target genes for oral delivery. Seven genes resulted in more than 90% mortality after microinjection. To evaluate RNAi efficacy by oral delivery of dsRNA, five genes were tested by feeding the insects on gene-specific dsRNA mixed with an artificial diet. Significant mortality of 43% and 45% was observed after 14 days of treatment with dsαCop and dsvATPase A, respectively. To elucidate the lower RNAi efficacy via oral delivery of dsRNA, ex vivo dsRNA degradation in the saliva and the midgut juice was performed, which indicated that the reduced RNAi efficacy is accompanied by a rapid degradation of dsRNA by digestive secretions.

CONCLUSION

This study proves that RNAi can be triggered by orally delivered dsRNA in N. viridula and can be exploited to control this economically important pest. The reduced stability of dsRNA in saliva and midgut that was observed indicates a need to further improve RNAi efficacy, for example by use of specific formulations.

Critical illness polyneuromyopathy: Functional impact after severe acquired brain injuries

OBJECTIVES

Critical illness polyneuropathy and myopathy (CIPNM) frequently affects critical patients and can occur after severe acquired brain injuries (sABI) influencing the functional recovery. We aimed to assess how the concomitance between CIPNM and sABI might influence the rehabilitative outcomes in terms of functional autonomy, oral feeding recovery and endotracheal tube weaning.

MATERIALS AND METHODS

Adult patients with sABI admitted to an intensive rehabilitation unit and underwent an electromyography examination within seven days after admission were included. Assessed rehabilitative outcomes at discharge were decannulation success and its timing, functional autonomy measured by the Functional Independence Measure (FIM) and the Glasgow outcome scale expanded (GOS-E) and oral feeding recovery assessed by the Functional Oral Intake Scale (FOIS) score.

RESULTS

Among the 224 included patients (81 (36%) females, age (median[IQR]): 68.73[21.66] years), 119 (53.1%) presented CIPNM at admission. Albeit the change of rehabilitative outcomes between admission and discharge was significant in all the sABI patients (P < .001 for ΔFOIS, ΔFIM and ΔGOS-E), those with a concomitant CIPNM achieved significantly lower scores as evaluated by Mann-Whitney tests (P < .001 for ΔFIM Δ and GOS-E; P < .005 for ΔFOIS). The CIPNM absence was associated with a higher probability to achieve functional autonomy (GOS-E > 4) (OR:4.57 (1.49/14.06); P < .01) and oral feeding recovery (FOIS ≥ 4) (OR:2.07 (1.07/3.99); P = .03) at discharge. CIPNM presence did not influence decannulation success but a longer time to cannula weaning was required (P < .01 in the log-rank test).

CONCLUSIONS

CIPMN significantly affects the rehabilitative outcomes after a sABI and should be taken into account for better rehabilitative handling.

Effect of SINC Feeding Protocol on Weight Gain, Transition to Oral Feeding, and the Length of Hospitalization in Preterm Infants: A Randomized Controlled Trial

BACKGROUND

The present study aims to test the effect of the Safe Individualized Nipple-Feeding Competence (SINC) protocol on the preterm infants' weight gain, transition to oral feeding, and duration of hospitalization.

METHODS

The procedure was designed as a single-blind, parallel-group randomized controlled trial. The trial was conducted in a neonatal intensive care unit (NICU) in Konya, Turkey. Data were collected from 80 preterm infants between February 2018 and March 2019. Infants (gestational weeks 28-33) were randomly assigned to the intervention (n = 39) and control groups (n = 41). The intervention group received the SINC feeding protocol, whereas the control group received the standard feeding. Data were collected using the Family Information Form, the Preterm Infant Follow-Up Form, and the SINC Protocol Evaluation Checklist. Infants were followed from hospitalization to discharge. The outcomes were weight gain, transition to oral feeding, and the length of hospitalization from birth to discharge. Pearson χ² test, Fisher exact test, independent t-test, Mann-Whitney U test, and general linear model test were used in analyzing the data.

RESULTS

The main effects of groups on weight measurements were found to be statistically significant (P < .001). There were no significant differences in terms of the transition from gavage to full oral feeding and the length of hospitalization (P > .05).

CONCLUSIONS

SINC protocol positively influences weight gain in preterm infants. It is important to evaluate different evidence-based feeding methods both as they apply to the NICU stay and how they may affect long-term outcomes of preterm infant.

Recovery of oral feeding in Japanese elderly people after long-term tube feeding: A challenge in Miyama Hospital

Context:

In Japan, many patients who cannot consume food orally are managed using external tube feeding over long periods. Although helpful in nutritional management, tube feeding significantly reduces a patient's quality of life.

Aims:

We examined the factors that affected the transition from tube to oral feeding in elderly people.

Settings and Design:

Single-center, retrospective, pilot study conducted from January 1, 2018 to December 28, 2019.

Methods and Materials:

We recruited patients who attempted to return to oral intake following tube feeding for >12 months at Miyama Hospital. Fourteen participants (male-to-female ratio = 6:8; age = 83.9 ± 2.6 years) attempted to resume oral feeding. We investigated patient diagnoses, duration of tube feeding, sex, swallowing reflex time, and Kohnan consciousness score. Patients with a swallowing reflex >4 s were administered banxia houpu tang.

Results:

Of the 14 patients, seven managed to resume oral feeding (group 1), while the remaining seven failed (group 2). The two groups of patients showed no significant difference in terms of mean age, duration of tube feeding, swallowing reflex time, and sex. However, the consciousness level of group 1 was significantly higher than that of group 2.

Conclusions:

Higher consciousness level in patients who successfully resumed oral feeding suggests that oral feeding should be considered in patients with adequate consciousness.

Association Between Active Gait Training for Severely Disabled Patients with Nasogastric Tube Feeding or Gastrostoma and Recovery of Oral Feeding: A Retrospective Cohort Study

PURPOSE

This study evaluates the effect of introducing active gait training (AGT) to patients who are severely disabled with nasogastric tube feeding or gastrostoma on the recovery of oral feeding.

PATIENTS AND METHODS

We conducted a historical cohort study at a single rehabilitation center in Japan between January 2013 and December 2019. In this study, 154 severely disabled patients with nasogastric tube feeding or gastrostoma due to neurological diseases or disuse syndrome admitted in a rehabilitation ward were included, and their median age was 84 years. AGT was systematically implemented in August 2016, which consisted of using orthosis or assistance from physical therapists. We compared the recovery of oral feeding between periods before (Pre-AGT) and after (Post-AGT) the introduction of AGT.

RESULTS

Among the 154 severely disabled patients included, 59 (38%) were admitted in the Post-AGT period. Twenty-eight (30%) and 54 patients (92%) started gait training in the Pre-AGT and Post-AGT periods, respectively (p < 0.001). Significantly more patients recovered oral feeding in the Post-AGT than in the Pre-AGT periods (49% vs 19%, respectively; p < 0.001). After the introduction of AGT, the adjusted hazard ratio for the recovery of oral feeding was 4.0 (95% confidence interval, 1.9-8.3; p < 0.001).

CONCLUSION

After the introduction of AGT to patients, increased recovery of oral feeding was observed in this retrospective evaluation. AGT should be considered for patients with tube feeding to help them recover oral feeding even if patients were severely disabled and required full assistance during gait training.

Characterizing International Approaches to Weaning Children From Tube Feeding: A Scoping Review

Approaches to tube weaning enterally fed children and evaluating outcomes vary widely. This limits the utility of research for identifying both "what works" and successful implementation of research outcomes. We used a qualitative scoping review methodology to examine internationally published research. Our primary aim was to identify the main philosophies underpinning intervention design and the main outcome variables used to demonstrate success of existing programs. This information can be used to inform future research design and clinical practice. Literature up until June 2019 was sourced via Medline, Scopus, Ovid, and CINHAL databases; hand searching; and gray literature using Google Advanced Search. Three predominant approaches to tube-weaning interventions were identified: behavioral, child- and family-centered, and biomedical. A wide range of intervention variables were identified, with the level of parental involvement and the use of hunger provocation varying between approaches. Our Review also confirms that there is no consistency in outcome measures used, limiting comparability between programs. We suggest that the role of parents in the weaning process and its impact on both the child and the parent/carer while transitioning from enteral to oral eating are insufficiently understood. We discuss these findings in the context of a suggested framework for future research.

Analysis of post-operative efficacy and pharyngeal fistula healing in patients with laryngeal cancer treated with post-operative enteral nutrition support nursing combined with early oral feeding

The present study aimed to analyze the effects of post-operative enteral nutrition support nursing combined with early oral feeding on post-operative efficacy and pharyngeal fistula (PF) healing in patients with laryngeal cancer (LC). A retrospective analysis of 133 patients with LC, who underwent laryngectomy between May 2014 and September 2016, was conducted. Of these patients, 61 patients (control group) were treated with enteral nutrition support nursing combined with nasogastric feeding, and 72 patients (observation group) were treated with enteral nutrition support nursing combined with early oral feeding. Levels of serum albumin (ALB), pre-albumin (PA), hemoglobin (Hb) and the lymphocyte count (LYM) were compared before and after surgery (7 and 14th post-operative days). The post-operative weight, upper arm muscle circumference (UAMC), triceps skinfold (TSF), post-operative infection, adverse reactions and PF healing were also measured. No differences were observed between the control and observation groups before surgery (all P>0.05). ALB, Hb, PA and LYM were significantly decreased in the control group on the 7 and 14th days post-operatively compared with those in the observation group (all P<0.05). Five patients in the control group presented with PF during treatment, and seven patients in the observation group suffered from PF after surgery. No difference in the average healing time of PF, number of patients with post-operative infection and adverse reactions were observed between the two groups (all P>0.05). The weight and UAMC in the observation group, 14 days post-operatively, were significantly higher than those before surgery in the same patients and in the control group (all P<0.05), whereas no difference in TSF (P>0.05) was observed. No differences in weight, UAMC and TSF were revealed in the control group before surgery and on the 14th day post-operatively (all P>0.05). Thus, post-operative enteral nutrition support nursing combined with early oral feeding resulted in significant improvement in the post-operative efficacy of patients with LC and had no effect on PF healing.

Intolerance to early oral feeding in enhanced recovery after colorectal surgery: an early red flag?

AIM

Enhanced recovery programmes (ERPs) involve early postoperative oral feeding. The aim of this study was to test the hypothesis that intolerance to early feeding was associated with a complicated postoperative course.

METHOD

A retrospective cohort analysis of the prospective multicentre database developed by the Francophone Group for Enhanced Recovery after Surgery (GRACE) was undertaken. Seventy-one centres in Belgium, France and Switzerland participated in the study. All patients were encouraged to eat within 24 h after surgery. Patients were separated into two groups according to whether early feeding was well tolerated (WT) or poorly tolerated (PT). The primary outcome measure was overall postoperative complications. Secondary outcome measures were unplanned reoperation, early mobilization rate and duration of postoperative hospital stay.

RESULTS

Among the cohort of 3034 patients, early feeding was WT in 2614 patients (WT group) and PT in 420 patients (PT group). There were significantly more postoperative complications in the PT group than in the WT group (52.1% vs 17.0%, respectively; P = 0.001), namely more unplanned reoperations, less early mobilization and longer postoperative hospital stay. Multivariate analyses confirmed that PT early feeding was the main and dominant independent factor for postoperative complications [OR 4.47 (95% CI3.49-5.72); P < 0.001], more unplanned reoperations and longer hospital stay.

CONCLUSIONS

This study demonstrates a close relationship between intolerance to early feeding and a complicated postoperative course. Whenever this simple very early red flag is observed, discharge should not be planned until postoperative complications have been ruled out.

Impact of High Flow Nasal Cannula Therapy on Oral Feeding in Very Low Birth Weight Infants with Chronic Lung Disease

Previous studies on high-flow nasal cannula (HFNC) in very-low-birth-weight infants (VLBWIs) focused on comparing HFNC with nasal continuous positive airway pressure (nCPAP) to determine the usefulness of HFNC as a backup in the case of extubation failure and nasal trauma; however, the studies did not consider oral feeding. This retrospective case-control study aimed at elucidating whether HFNC could prevent the delay in feeding and achievement of full oral feeding in VLBWIs with chronic lung disease (CLD). Forty five VLBWIs were enrolled in this study: an HFNC group (n = 11) that was supported by HFNC at oral feeding initiation, and a non-HFNC group (n = 34) that could start oral feeding without HFNC. The gestational age and birth weight of the HFNC group were lower than those in the non-HFNC group. The median duration of exposure to oxygen and neonatal intensive care unit stay were comparable in both groups. The timings of oral feeding initiation and full oral feeding achievement in both groups were not significantly different: 35.3 (33.0 - 38.1) vs. 35.5 (33.7 - 42.4) weeks (P = 0.91) for the HFNC and 38.6 (34.4 - 42.3) vs. 36.7 (34.6 - 44.4) weeks postmenstrual age (P = 0.29) for the non-HFNC. Clinically significant aspiration pneumonia during the period of oral feeding was not observed in the HFNC group. Respiratory support by HFNC in VLBWIs with CLD might prevent oral feeding delay. Initiation of oral feeding of VLBWIs on HFNC might be safe and might accelerate the achievement of oral feeding milestones.

The Impact of Neurobehavior on Feeding Outcomes in Neonates with Congenital Heart Disease

OBJECTIVE

To evaluate the association between neonatal neurobehavioral state and oral feeding outcomes following congenital heart disease (CHD) surgery.

STUDY DESIGN

This single center retrospective cohort study described neonates undergoing cardiac surgery evaluated perioperatively with the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS). We compared NNNS attention scores, which evaluates neonates' ability to orient and fixate on stimuli, with the feeding outcomes percentage of feeds taken orally at discharge and time to reach full oral feeds using regression analyses. Models were constructed for both preoperative and postoperative NNNS evaluations.

RESULTS

Between August 2015 and October 2017, 124 neonates underwent 89 preoperative and 97 postoperative NNNS evaluations. In multivariable Cox regression, higher preoperative NNNS attention scores were associated with a shorter time to achieve full oral feeds (hazard ratio 1.4; 95% CI 1.0‒2.0; P = .047). This relationship was not seen for post-operative NNNS attention scores or percentage of oral feeds at discharge. Depending on the model, younger age at surgery, increased ventilator days, increased length of stay, and single or 2-ventricle anatomy with aortic arch obstruction were associated with lower percentage of oral feeds at discharge and/or delay in full oral feeds.

CONCLUSIONS

Higher neonatal attention before cardiac surgery is associated with improved feeding outcomes. Prospective assessment of neonatal neurobehavioral state may be a novel approach to predict and target interventions to improve feeding outcomes in CHD. Future studies should examine the impact of intrinsic neurodevelopmental delay vs environmental adaptation on the neurobehavioral state of neonates with CHD.

Effects of early oral feeding versus delayed feeding on gastrointestinal function of post-caesarean section women in a tertiary hospital in Enugu, Nigeria: A randomized controlled trial

Background

Initiation of oral intake after caesarean delivery influences return of bowel function, ambulation of patients, and time to recover from surgery.

Aims

To assess the effect of early versus delayed initiation of oral feeding after caesarean delivery on gastrointestinal function, pace of recovery, and maternal satisfaction at University of Nigeria Teaching Hospital (UNTH), Enugu.

Settings and Design

This was a randomized controlled study of women who had caesarean delivery from December 2012 to September 2013 at the Department of Obstetrics and Gynaecology UNTH, Enugu, Nigeria. In all, 282 participants were randomized equally into early and delayed oral feeding groups. Oral intake was commenced at 8 h post operation for those in early feeding group and at 48 h post operation for those in delayed feeding group. The primary outcome measure was the time interval from the end of surgery to the return of bowel sound.

Subjects and Methods

Analysis was by intention-to-treat. SPSS version 16 was used for data entry and analysis was done using cross tabulation and Fisher's exact test for categorical data and independent sample T-test for continuous data. P value of < 0.05 was regarded as statistically significant.

Results

Apart from gastrointestinal complications, there was significant difference between early and delayed feeding groups with respect to all the outcome variables: return of bowel sound (17.8 ± 4.3 h vs 35.2 ± 9.4 h; P < 0.001), return to regular diet 48.9 ± 5.2 h vs 85.5 ± 7.0 h; P < 0.001), postoperative time interval to ambulation (20.3 ± 7.0 h vs 30.9 ± 9.6 h; P < 0.001), and maternal satisfaction as estimated with visual analog scale (86.4 ± 10.4 mm vs 40.0 ± 25.9 mm; P < 0.001).

Conclusion

Early initiation of oral feeding after caesarean delivery is safe and may be associated with earlier return of bowel functions, earlier ambulation, shorter postoperative time interval to become eligible for discharge, and high maternal satisfaction.

A key developmental step for preterm babies: achievement of full oral feeding

Aims: To investigate timing of oral feeding (OF) introduction and full oral feeding (FOF) achievement in preterm infants and to explore factors associated with feeding progression.Methods: Retrospective review of 100 medical records of preterms ≤32 weeks of gestation (GA) without major complications. Outcome measures were timing of OF introduction, transition time from nasogastric tube to FOF and FOF achievement. Variables such as sex, twins, GA, birthweight, respiratory supports used and duration of tube feeding, were also considered.Results: Post menstrual age (PMA) for OF introduction was 33.6 ± 1.1 weeks. FOF was achieved at 35.1 ± 1.5 weeks. PMA at OF introduction and PMA at FOF correlated with: birthweight (p = .0001, p = .001); duration of respiratory supports (p = 0.01, p = .0001); PMA at which respiratory supports were stopped (p = .0001, p = .0001); age of introduction of gavage (p = .0001, p = .003) and time of utilization of tube feeding (p = .02, p = .0001). Transition time was 1.5 ± 8.5 days. PMA at OF introduction significantly influenced PMA at FOF (p = .0001, r = .61). OF introduction, transition time and FOF were correlated with duration of hospitalization (p = .004, p = .0001, p = .008).Conclusions: The achievement of feeding skills is confirmed to affect length of hospitalization, but the earlier you introduce OF, the earlier you reach FOF, so introduction should be anticipated. There is a clear trend to favor higher birthweight classes in FOF achievement. Feeding tube placement and need for respiratory supports may represent a nociceptive experience delaying feeding skills' achievement. This highlights the importance of prospective studies investigating the role of preventative interventions.

Predictors of Oral Feeding Resumption after Stroke in a Rehabilitation Hospital: A Retrospective Study

BACKGROUND

Dysphagia is common after stroke, requiring exclusive enteral feeding in 20% of patients. Recovery of oral feeding is associated with increased quality of life, better functional outcomes, and decreased mortality rates. However, evidence is heterogeneous and not conclusive on which factors are predictive of oral feeding recovery for stroke patients in rehabilitation units.

AIM

To investigate predictors of complete oral feeding recovery.

DESIGN

Retrospective study.

SETTING

Intensive inpatient rehabilitation hospital.

POPULATION

Poststroke dysphagic individuals with enteral feeding.

METHODS

Retrospective chart review of demographic, clinical, rehabilitation, and swallowing factors. Univariate analysis and multivariate regression analysis were used to compare variables between the oral feeding recovery group and the enteral feeding group at discharge.

RESULTS

One hundred thirty-nine patients were included in the analysis. A total of 61.9% of the sample population resumed complete oral intake at discharge. There were statistically significant differences between the 2 groups in Functional Independence Measure cognitive score, clinical swallow evaluation, and instrumental swallow evaluation at admittance, and dysphagia rehabilitation. Multiple logistic regression analysis identified the absence of aspiration signs with liquids associated with a higher probability of the resumption of complete oral feeding (odds ratio [OR] 3.57; 95% confidence interval [CI] 1.07-11.89). Age between 73 and 79 years (OR .96; 95% CI .01-.58), the presence of aspiration and/or penetration (OR .22; 95% CI .07-.72), and the presence of residue (OR .14; 95%CI .04-.43) during fiberoptic endoscopic evaluation of swallowing presented lower probability of returning to complete oral feeding.

CONCLUSION

Several demographic and swallowing characteristics predicted oral feeding recovery. Absence of dysphagia signs documented on fiberoptic endoscopic evaluation of swallowing was the strongest predictor of complete oral feeding resumption.

Non-Nutritive Sucking in the Preterm Infant

OBJECTIVE

To identify the progression of non-nutritive sucking (NNS) across postmenstrual age (PMA) and to investigate the relationship of NNS with medical and social factors and oral feeding.

STUDY DESIGN

Fifty preterm infants born at ≤32 weeks gestation had NNS assessed weekly starting at 32 weeks PMA with the NTrainer System. Oral feeding was assessed at 38 weeks PMA.

RESULTS

There were increases in NNS bursts per minute (p = 0.005), NNS per minute (p < 0.0001), NNS per burst (p < 0.001), and peak pressure (p = 0.0003) with advancing PMA. Level of immaturity and medical complications were related to NNS measures (p < 0.05). NNS measures were not related to Neonatal Oral Motor Assessment Scale scores. Smaller weekly change in NNS peak pressure (p = 0.03; β = -1.4) was related to feeding success at 38 weeks PMA.

CONCLUSION

Infants demonstrated NNS early in gestation. Variability in NNS scores could reflect medical complications and immaturity. More stable sucking pressure across time was related to feeding success at 38 weeks PMA.

Ultrasonographic swallowing examination for early detection of neopharyngeal fistula after salvage total laryngectomy: A preliminary study

BACKGROUND

The current study investigated the feasibility of ultrasonographic swallowing examination (USSE) for the evaluation of neopharynx and early detection of neopharyngeal fistula after salvage total laryngectomy.

METHODS

A prospective case series-based study involving 16 patients who underwent salvage total laryngectomy was conducted. USSE was performed on postoperative days 5-7, and oral diet initiation was determined based on the USSE results.

RESULTS

Fistula of the neopharynx was detected in four patients (25%) via USSE, as was the specific site of the fistula. In these patients, oral diet was delayed and immediate interventions including ultrasound-guided fluid aspiration and compression dressing were applied, and all fistulas were subsequently closed. In the remaining 12 patients with no neopharyngeal fistula on USSE, an oral diet was started immediately and no fistula occurred.

CONCLUSIONS

USSE is a promising method for neopharynx evaluation and early detection of neopharyngeal fistula after salvage total laryngectomy.

Oral Feeding Challenges in Children With Tracheostomy Can Improve Feeding Outcomes, Even With the Finding of Aspiration

It has been suggested that oral feeding trial has therapeutic implications for improving oral-motor and swallowing function in infants and young children fed via an enteral tube or gastrostomy. This study aimed to investigate whether oral feeding challenges in children with tracheostomy could improve feeding outcomes, even with the finding of aspiration compared to those who did not receive oral feeding at all. Children (age <7 years) with tracheostomy who had thin fluid aspiration on videofluoroscopic swallowing study (VFSS) were included in this retrospective study. Enrolled children were then divided into two feeding method groups according to the physician's decision at the time of VFSS: oral feeding (OF) group and non-oral feeding (NOF) group. Data were obtained from 47 children (median age: 49.75 months, interquartile range [IQR]: 24.08-79.42). The incidence of pneumonia within 1 year after the VFSS was not different between NOF (n = 17) and OF (n = 30) groups. In OF group, 11 subjects achieved full oral feeding and 16 subjects were in partial oral feeding status 1 year after the VFSS. On the contrary, only one subject achieved full oral feeding and 5 subjects were in partial oral feeding status in NOF group (p < 0.001). Initial and follow-up penetration-aspiration scale on VFSS were different only in the OF group (p = 0.003). These results suggest that oral feeding challenges might be attempted even with the findings of aspiration in infants or young children with tracheostomy.

Transition From Nasogastric Tube to Oral Feeding: The Role of Parental Guided Responsive Feeding

Background and Objective: Strategies to transition preterm infants from tube to oral feeding vary greatly and the transition may take days to weeks. The study objective was to evaluate the effect of parental guided responsive feeding (PGRF) on this transition. Methods: We conducted a randomized controlled trial on infants born at <32 weeks gestation. The PGRF intervention was performed by parents, and included feeding intervals and volumes which were guided by the infants' behavioral cues of hunger and satiety. If a minimum volume was not taken orally, an intermediate volume was supplemented via nasogastric tube. The control group was traditionally fed (TF), with pre-planned volumes of intake and at given scheduled intervals. Results: The study comprised 67 infants (PGRF 32, TF 35). PGRF infants reached full oral feeding within less days (median 2 vs. 8 days, p = 0.001), at an earlier age (median 34.28 vs. 35.14 weeks, p < 0.001), returned to baseline weight gain at 35 weeks (1.77 ± 0.70 vs. 1.25 ± 0.63 g/kg/day, p = 0.002), were discharged earlier (36.34 ± 0.6 vs. 36.86 ± 0.9 weeks, p = 0.001), were more likely to be fed by their parents (p < 0.001), and experienced less apnea/bradycardia events at 34 weeks (median 3.5 vs. 9 per week p = 0.047) compared to the TF infants. The regression model demonstrated that independent variables predicted 43.7% of the variance of time to full oral feeding [F _{(9, 65)} = 4.84 p < 0.001]. The only significant variable was feeding group (B = -6.43 p < 0.001); The PGRF infants were more likely to reach full oral feeding earlier. Conclusion: PGRF is safe, and associated with short-term advantages, higher parental engagement, and earlier discharge. Clinical Trial Registration: Identifier: SHEBA-12-9574-IM-CTIL; "Adjusted Individual Oral Feeding for Improving Short and Long Term Outcomes of Preterm Infants."

Psychometrics of the Functional Oral Intake Scale for Infants

This study aimed to investigate the reliability and validity of the Functional Oral Intake Scale (FOIS) for infants. Infants (age, <1 year) who underwent a videofluoroscopic swallowing study (VFSS) were included in this retrospective study. Their nutrition records at the time of the VFSS were separately evaluated by two raters using the five-point FOIS for infants. Categorical swallowing and aspiration impairment scale data were also obtained from the VFSS. The inter-rater reliability of the FOIS for infants was high (95.5% absolute agreement) among the 201 evaluated infants, and this scale was significantly correlated with aspiration severity in the VFSS. We also investigated whether infants with partial oral feeding (POF) at the FOIS evaluation had achieved full oral feeding within 1 year of the evaluation and used this information to estimate whether the caloric contribution, as well as consistency of oral feeding, affected the feeding outcomes. This analysis included 33 infants who were receiving both oral and tube feeding (i.e., POF). Among them, 26 infants achieved full oral feeding (FOF) without tube feeding after 1 year. Their initial contribution from oral feeding was higher than that in infants who still maintained POF after 1 year (28.46 ± 22.79 vs. 6.00 ± 5.45%, p < 0.001). The five-point FOIS for infants, which reflected the expansion of their oral diet with growth, had adequate reliability and validity. The caloric contribution as well as consistency of oral feeding could be used to distinguish FOIS levels 2 and 3, which correspond to the POF status in infants.

Oral Sensorimotor Intervention Enhances Breastfeeding Establishment in Preterm Infants

OBJECTIVE

To assess the efficacy of an oral sensorimotor intervention on breastfeeding establishment and maintenance in preterm infants.

STUDY DESIGN

Thirty-one preterm infants born ≤34 weeks gestation were randomized into an experimental or control group. The experimental group received a 15-minute program consisting of stroking the peri-oral structures for the first 5 minutes, tongue exercises for the next 5 minutes, followed by non-nutritive sucking for the final 5 minutes. The control group received a sham intervention for the same duration. The interventions were administered once daily for 10 days. The outcomes included: time to attainment of full oral feeding, breastfeeding acquisition (i.e., ≥50% of direct breastfeeding at hospital discharge), breastfeeding skill assessment using the Preterm Infant Breastfeeding Behavior Scale (PIBBS), length of hospitalization, and breastfeeding maintenance at 3 and 6 months posthospitalization.

RESULTS

Full oral feeding was attained earlier in the experimental group compared with the control (10.7 ± 2.1 vs. 19.3 ± 3.6 days, p < 0.01). This was associated with a greater number of infants in the intervention group acquiring breastfeeding at hospital discharge compared with the controls (n = 11 vs. 5, p = 0.049). There was no statistical difference in PIBBS score, length of hospitalization, and breastfeeding rates at 3 and 6 months posthospitalization between the two groups (all tests, p > 0.32).

CONCLUSIONS

An oral sensorimotor intervention accelerated the achievement of full oral feeding and enhanced direct breastfeeding rates at hospital discharge only. Provision of an oral sensorimotor intervention is a safe and low-cost intervention that may increase breastfeeding rates in a highly vulnerable population.

Impact of Neonatal Intensive Care Unit oral feeding on neuropsychomotor outcomes at 9 months of corrected age in Chinese low-birthweight preterm infants: A retrospective study

AIMS AND OBJECTIVES

To examine the changes in neuropsychomotor development and investigate the effect of feeding progression in Neonatal Intensive Care Unit (NICU) on neuropsychomotor outcomes in low-birthweight preterm infants within 9 months of corrected age.

BACKGROUND

Low-birthweight (LBW) preterm infants (<37 weeks of gestation and birthweight <2,500 g) are at a high risk for neuropsychomotor development delay. Therefore, exploring NICU practices related to neuropsychomotor development is important.

DESIGN

This is a retrospective hospital-based cohort study.

METHODS

This study included 196 LBW preterm infants who were admitted to the NICU between January 2014-March 2016 and attended the follow-up growth evaluation in the clinic after discharge. The neuropsychomotor development of preterm infants was assessed every 3 months to a corrected age of 9 months using the paediatric neuropsychomotor diagnostic scale (PNDS). Generalised linear mixed models (GLMM) were performed.

RESULTS

The total PNDS scores had a downward trend, but the difference on pairwise comparison was not statistically significant. In total, 18.1%, 15.2% and 9.7% of preterm infants were examined for neuropsychomotor disorders at 3, 6 and 9 months of corrected age, respectively. The result of GLMM showed that the early initiation of oral feeding with breast milk was associated with optimal neuropsychomotor development. The first 3 months of corrected age is the critical period for neurodevelopmental disorders.

CONCLUSIONS

This study showed the importance of the early initiation of oral feeding with breast milk as early as possible within the NICU setting and highlighted the importance of close developmental follow-up.

RELEVANCE TO CLINICAL PRACTICE

The early initiation of oral feeding with breast milk may be recommended to promote neuropsychomotor development of LBW preterm infants within the NICU setting. Early identification of neuropsychomotor developmental delays within the first 3 months may guide early interventions.

Oral feeding practices and discharge timing for moderately preterm infants

BACKGROUND

Oral feeding skills of moderately preterm infants are not mature at birth.

AIMS

To establish the relationship between postmenstrual age at introduction of first oral feeding and attainment of full oral feeding and hospital discharge for moderately preterm infants.

STUDY DESIGN

Multicenter retrospective analysis of a prospective cohort of moderately preterm infants admitted to a Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network hospital.

SUBJECTS

6146 infants born at 29-33 weeks' gestation from January 2012 to November 2013.

OUTCOME MEASURES

Postmenstrual age at full oral feeding and at hospital discharge.

RESULTS

The median postmenstrual age at first oral feeding was 33.9 weeks (interquartile range 33.1-34.3). For each week earlier at first oral feeding, full oral feeding occurred 4.5 days earlier (p < 0.0001) and hospital stay was shortened by 3.4 days (p < 0.0001). Higher birth weight (p < 0.0001) and black maternal race (p = 0.0001) were associated with younger postmenstrual age at full oral feeding and at discharge.

CONCLUSION

Moderately preterm infants with earlier introduction of oral feeding achieved earlier full oral feeding and hospital discharge.

"Music & Memory" and improved swallowing in advanced dementia

Background

Dysphagia and difficulty with eating affects a significant portion of individuals with advanced dementia. Such problems with oral intake can have serious health consequences including mealtime distress, dehydration and malnutrition, aspiration, reduced quality of life, and increased mortality risk.

Design

We present the first data indicating that “Music & Memory” interventions improve swallowing in individuals with advanced dementia, thereby making oral feeding easier and potentially diminishing reliance on PEG.

Setting

Columbia Health Care Center, Wyocena, WI (with Music&Memory.org, Mineola, NY and Stony Brook University).

Participants

Residents with advanced dementia (N = 5). Measurements: Observation by eight professional caregivers.

Results

(1) Enhanced swallowing mechanism with Music & Memory prior to dining; (2) decreased incidents of choking during mealtime; (3) improved nutritional status; (4) reduced weight loss; (5) reduced need for speech interventions; (6) enhanced quality of life.

Conclusions

The preliminary results call for additional research.

Gabapentin Improves Oral Feeding in Neurologically Intact Infants With Abdominal Disorders

Feeding intolerance, poor oral feeding skills, and retching are common symptoms seen in medically complex infants with a history of abdominal disorders and surgical interventions, such as gastrostomy tube placement and Nissen fundoplication. Visceral hyperalgesia may play a role in the underlying pathophysiology. We report the use of orally administered gabapentin in 3 infants with presumed visceral hyperalgesia presenting as poor tolerance of enteral and oral feeds. Retching and outward discomfort associated with feeds was resolved within 2 to 3 days of initiation of therapy. Full oral feeds were obtained in all 3 patients within 3 to 4 months of starting gabapentin without changing adjunctive medications or therapies. After attainment of full oral feeds, all patients were successfully weaned off gabapentin over a month, with no notable side effects, signs of withdrawal, or impact on ability to feed by mouth.