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1.
Short versus long feeding interval for bolus feedings in very preterm infants.
Ibrahim, NR, Van Rostenberghe, H, Ho, JJ, Nasir, A
The Cochrane database of systematic reviews. 2021;(8):CD012322
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Abstract
BACKGROUND There is presently no certainty about the ideal feeding intervals for preterm infants. Shorter feeding intervals of, for example, two hours, have the theoretical advantage of allowing smaller volumes of milk. This may have the potential to reduce the incidence and severity of gastro-oesophageal reflux. Longer feeding intervals have the theoretical advantage of allowing more gastric emptying between two feeds. This potentially provides periods of rest (and thus less hyperaemia) for an immature digestive tract. OBJECTIVES To determine the safety of shorter feeding intervals (two hours or shorter) versus longer feeding intervals (three hours or more) and to compare the effects in terms of days taken to regain birth weight and to achieve full feeding. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to run comprehensive searches in CENTRAL (2020, Issue 6) and Ovid MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions, and CINAHL on 25 June 2020. We searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs. SELECTION CRITERIA We included RCTs and quasi-RCTs comparing short (e.g. one or two hours) versus long (e.g. three or four hours) feeding intervals in preterm infants of any birth weight, all or most of whom were less than 32 weeks' gestation. Infants could be of any postnatal age at trial entry, but eligible infants should not have received feeds before study entry, with the exception of minimal enteral feeding. We included studies of nasogastric or orogastric bolus feeding, breast milk or formula, in which the feeding interval is the intervention. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We used the GRADE approach to assess the certainty of evidence. Our primary outcomes were days taken to achieve full enteral feeding and days to regain birth weight. Our other outcomes were duration of hospital stay, episodes of necrotising enterocolitis (NEC) and growth during hospital stay (weight, length and head circumference). MAIN RESULTS We included four RCTs, involving 417 infants in the review. One study involving 350 infants is awaiting classification. All studies compared two-hourly versus three-hourly feeding interval. The risk of bias of the included studies was generally low, but all studies had high risk of performance bias due to lack of blinding of the intervention. Three studies were included in meta-analysis for the number of days taken to achieve full enteral feeding (351 participants). The mean days to achieve full feeds was between eight and 11 days. There was little or no difference in days taken to achieve full enteral feeding between two-hourly and three-hourly feeding, but this finding was of low certainty (mean difference (MD) ‒0.62, 95% confidence interval (CI) ‒1.60 to 0.36). There was low-certainty evidence that the days taken to regain birth weight may be slightly longer in infants receiving two-hourly feeding than in those receiving three-hourly feeding (MD 1.15, 95% CI 0.11 to 2.20; 3 studies, 350 participants). We are uncertain whether shorter feeding intervals have any effect on any of our secondary outcomes including the duration of hospital stay (MD ‒3.36, 95% CI ‒9.18 to 2.46; 2 studies, 207 participants; very low-certainty evidence) and the risk of NEC (typical risk ratio 1.07, 95% CI 0.54 to 2.11; 4 studies, 417 participants; low-certainty evidence). No study reported growth during hospital stay. AUTHORS' CONCLUSIONS The low-certainty evidence we found in this review suggests that there may be no clinically important differences between two- and three-hourly feeding intervals. There is insufficient information about potential feeding complications and in particular NEC. No studies have looked at the effect of other feeding intervals and there is no long-term data on neurodevelopment or growth.
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2.
Human milk fortification: the clinician and parent perspectives.
Hair, AB, Ferguson, J, Grogan, C, Kim, JH, Taylor, SN
Pediatric research. 2020;(Suppl 1):25-29
Abstract
This study reports on the human milk fortification session at the 2019 NEC Society Symposium, which included clinicians and parents discussing the evidence comparing fortification options such as efficacy, safety, cost effectiveness, and the need for parents to be informed about fortifier choice. With the current literature available and the varying standard of care practices for human milk fortification, further studies are needed to determine the most complete diet for preterm infants. The optimal diet would not only provide key nutrients and energy for growth and development, but also improve short- and long-term outcomes. Parents, as advocates and providers for their infant, should be informed, educated, and included in the discussion and decisions regarding fortification of human milk for their infant.
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3.
Protein intakes to optimize outcomes for preterm infants.
Embleton, ND, van den Akker, CHP
Seminars in perinatology. 2019;(7):151154
Abstract
Proteins are key structural components of all human cells and are also involved in key physiologic processes through their roles as enzymes, hormones and transport proteins. Protein requirements are substantially higher in preterm infants than those born at term, yet inadequate protein intakes are a common problem on many neonatal units. Very preterm infants (VPT, <32 weeks) commonly receive parenteral amino acid solutions which are typically commenced on admission, and increased over the next few days. Several recent studies have explored differing parenteral amino acid intakes in the first few days, and recommendations have recently been updated. Parenteral nutrition intakes are decreased as enteral feeds are tolerated, but human milk alone will not meet protein needs in most VPT and supplementation or fortification will be required. This review paper considers basic protein and amino acid physiology in the newborn period, and the evidence base for current recommendations.
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Nutrition and neurodevelopmental outcomes in preterm infants: a systematic review.
Chan, SH, Johnson, MJ, Leaf, AA, Vollmer, B
Acta paediatrica (Oslo, Norway : 1992). 2016;(6):587-99
Abstract
UNLABELLED A systematic review with meta-analysis was carried out to investigate the effects of increased nutritional intake, via either macronutrient or multinutrient intervention, during the neonatal period on neurodevelopmental outcomes in infants born at <32 weeks of gestation or weighing <1501 g at birth. CONCLUSION Although the relationship remains unclear, increased early nutrition may reduce neurodevelopmental impairment in this group of infants. Future research should focus on using standardised nutritional interventions and an agreed neurodevelopmental assessment battery.
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5.
Guidelines for feeding very low birth weight infants.
Dutta, S, Singh, B, Chessell, L, Wilson, J, Janes, M, McDonald, K, Shahid, S, Gardner, VA, Hjartarson, A, Purcha, M, et al
Nutrients. 2015;(1):423-42
Abstract
Despite the fact that feeding a very low birth weight (VLBW) neonate is a fundamental and inevitable part of its management, this is a field which is beset with controversies. Optimal nutrition improves growth and neurological outcomes, and reduces the incidence of sepsis and possibly even retinopathy of prematurity. There is a great deal of heterogeneity of practice among neonatologists and pediatricians regarding feeding VLBW infants. A working group on feeding guidelines for VLBW infants was constituted in McMaster University, Canada. The group listed a number of important questions that had to be answered with respect to feeding VLBW infants, systematically reviewed the literature, critically appraised the level of evidence, and generated a comprehensive set of guidelines. These guidelines form the basis of this state-of-art review. The review touches upon trophic feeding, nutritional feeding, fortification, feeding in special circumstances, assessment of feed tolerance, and management of gastric residuals, gastro-esophageal reflux, and glycerin enemas.
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6.
Sound reduction management in the neonatal intensive care unit for preterm or very low birth weight infants.
Almadhoob, A, Ohlsson, A
The Cochrane database of systematic reviews. 2015;:CD010333
Abstract
BACKGROUND Infants in the neonatal intensive care unit (NICU) are subjected to stress, including sound of high intensity. The sound environment in the NICU is louder than most home or office environments and contains disturbing noises of short duration and at irregular intervals. There are competing auditory signals that frequently challenge preterm infants, staff and parents. The sound levels in NICUs often exceed the maximum acceptable level of 45 decibels (dB), recommended by the American Academy of Pediatrics. Hearing impairment is diagnosed in 2% to 10% of preterm infants versus 0.1% of the general paediatric population. Noise may cause apnoea, hypoxaemia, alternation in oxygen saturation, and increased oxygen consumption secondary to elevated heart and respiratory rates and may, therefore, decrease the amount of calories available for growth. Elevated levels of speech are needed to overcome the noisy environment in the NICU, thereby increasing the negative impacts on staff, newborns, and their families. High noise levels are associated with an increased rate of errors and accidents, leading to decreased performance among staff. The aim of interventions included in this review is to reduce sound levels to 45 dB or less. This can be achieved by lowering the sound levels in an entire unit, treating the infant in a section of a NICU, in a 'private' room, or in incubators in which the sound levels are controlled, or reducing the sound levels that reaches the individual infant by using earmuffs or earplugs. By lowering the sound levels that reach the neonate, the resulting stress on the cardiovascular, respiratory, neurological, and endocrine systems can be diminished, thereby promoting growth and reducing adverse neonatal outcomes. OBJECTIVES Primary objectiveTo determine the effects of sound reduction on growth and long-term neurodevelopmental outcomes of neonates. Secondary objectives1. To evaluate the effects of sound reduction on short-term medical outcomes (bronchopulmonary dysplasia, intraventricular haemorrhage, periventricular leukomalacia, retinopathy of prematurity).2. To evaluate the effects of sound reduction on sleep patterns at three months of age.3. To evaluate the effects of sound reduction on staff performance.4. To evaluate the effects of sound reduction in the neonatal intensive care unit (NICU) on parents' satisfaction with the care. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library), MEDLINE, EMBASE, CINAHL, abstracts from scientific meetings, clinical trials registries (clinicaltrials.gov; controlled-trials.com; and who.int/ictrp), Pediatric Academic Societies Annual meetings 2000 to 2014 (Abstracts2View(TM)), reference lists of identified trials, and reviews to November 2014. SELECTION CRITERIA Preterm infants (< 32 weeks' postmenstrual age (PMA) or < 1500 g birth weight) cared for in the resuscitation area, during transport, or once admitted to a NICU or a stepdown unit. DATA COLLECTION AND ANALYSIS We performed data collection and analyses according to the Cochrane Neonatal Review Group. MAIN RESULTS One small, high quality study assessing the effects of silicone earplugs versus no earplugs qualified for inclusion. The original inclusion criteria in our protocol stipulated an age of < 48 hours at the time of initiating sound reduction. We made a deviation from our protocol and included this study in which some infants would have been > 48 hours old. There was no significant difference in weight at 34 weeks postmenstrual age (PMA): mean difference (MD) 111 g (95% confidence interval (CI) -151 to 374 g) (n = 23). There was no significant difference in weight at 18 to 22 months corrected age between the groups: MD 0.31 kg, 95% CI -1.53 to 2.16 kg (n = 14). There was a significant difference in Mental Developmental Index (Bayley II) favouring the silicone earplugs group at 18 to 22 months corrected age: MD 14.00, 95% CI 3.13 to 24.87 (n = 12), but not for Psychomotor Development Index (Bayley II) at 18 to 22 months corrected age: MD -2.16, 95% CI -18.44 to 14.12 (n =12). AUTHORS' CONCLUSIONS To date, only 34 infants have been enrolled in a randomised controlled trial (RCT) testing the effectiveness of reducing sound levels that reach the infants' ears in the NICU. Based on the small sample size of this single trial, we cannot make any recommendations for clinical practice. Larger, well designed, conducted and reported trials are needed.
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7.
Practice of enteral nutrition in very low birth weight and extremely low birth weight infants.
Senterre, T
World review of nutrition and dietetics. 2014;:201-14
Abstract
The perinatal period is critical for human development. The brain of very low birth weight (VLBW, <1,500 g) infants is particularly vulnerable to undernutrition. Enteral nutrition is of major importance for the growth and the development of the gastrointestinal tract, which depends on the amount and composition of feeds. Feeding intolerance and the risk of necrotizing enterocolitis (NEC) are key concerns with enteral nutrition in VLBW infants. Controversies exist on how to feed VLBW infants during the first weeks of life, particularly in extremely low birth weight (ELBW, <1,000 g) infants. Unreasonable concerns lead to iatrogenic malnutrition, gastrointestinal atrophy, and parenteral nutrition-related complications. Many studies in the field of nutrition during the past decade demonstrated that some feeding regimens have significant benefits. There is strong evidence that the use of human milk (HM) reduces the risk of NEC and provides major advantages in VLBW infants. The feeding of fortified HM should be promoted and HM banking should be further developed to allow access to pasteurized donor HM for VLBW infants with an insufficient intake of their own mother's milk. Early enteral feeding should be promoted soon after birth to enhance gastrointestinal maturation, growth and functional development. Continuous- or short-interval intermittent feeding seems to provide better gastrointestinal tolerance and faster achievement of full enteral feeding. Feeding advancements of 20-30 ml/kg/day in VLBW infants ≥1,000 g and of 15-25 ml/kg/day in ELBW infants are reasonable strategies. Any suspicion of feeding intolerance implies short-interval evaluation to decide whether interruption of enteral feeding or its restart after a transient interruption are appropriate. One should always strive for maintaining at least minimal enteral feeding, rather than complete interruption of enteral feeding.
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8.
Human milk and neurodevelopment in children with very low birth weight: a systematic review.
Koo, W, Tank, S, Martin, S, Shi, R
Nutrition journal. 2014;:94
Abstract
Human milk (HM) contains critical nutrients and possibly other neurotrophic factors that could benefit the less developed brain of preterm infants, particularly those with very low birth weight (VLBW). This study aims to systematically review the original studies to determine whether there is a reproducible independent effect of HM feeding on neurodevelopment outcome in preterm VLBW infants. Search of seven databases (PubMed, Cochrane, CINAHL, Embase, Proquest Research Library, Google Scholar, and Web of Science) identified 24 original studies. Each study was evaluated by two authors independently for 8 non-nutritive (study design, target population, a priori power calculation, adjustment for baseline growth status, postnatal complication, other confounders, observer blinding to feeding status, effect size) and 5 nutritive (definition and duration of HM intake, use of HM fortifier, source of HM data, infant formula used) methodology parameters, and consistency and directness of outcome measures. Thirteen reports of preterm infants with wide ranges of birth weights were excluded as none provided sufficient data to delineate the effects of HM feeding on developmental outcome of subjects with VLBW. Eleven reports included only VLBW children and 7 studies were reviewed after elimination of preliminary data from same cohort or lack of appropriate standardized testing or control group. These 7 studies (n = 18 to 704, median 219) were performed at <3 years (3 studies) and at 5 to 11 years (4 studies). Six studies were secondary analysis of data from other studies. Each study met or only partially met 4 to 10 methodological parameters. VLBW children with no neurological impairment fed HM achieved normal or low normal range of test scores. Formula feeding using older formulations was associated with a lower subtest score in 4 studies. There is no randomized clinical trial comparing the neurodevelopment outcome of HM versus formula or minimal HM feeding that included only children with VLBW. The role of HM in the neurodevelopment and cognitive function of VLBW children needs reassessment with high quality studies in the context of current formulations of HM fortifier and preterm formula.
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9.
Gastric residual evaluation in preterm neonates: a useful monitoring technique or a hindrance?
Li, YF, Lin, HC, Torrazza, RM, Parker, L, Talaga, E, Neu, J
Pediatrics and neonatology. 2014;(5):335-40
Abstract
It is routine practice in most neonatal intensive care units to measure the volume and color of gastric residuals (GRs) prior to enteral bolus feedings in preterm very low birth weight infants. However, there is paucity of evidence supporting the routine use of this technique. Moreover, owing to the lack of uniform standards in the management of GRs, wide variations exist as to what constitutes significant GR volume, the importance of GR color and frequency of GR evaluation, and the color or volume standards that dictate discarding or returning GRs. The presence of large GR volumes or green-colored residuals prior to feeding often prompts subsequent feedings to be withheld or reduced because of possible necrotizing enterocolitis resulting in delays in enteral feeding. Cessation or delays in enteral feeding may result in extrauterine growth restriction, a known risk factor for poor neurodevelopmental and growth outcomes in preterm very low birth weight infants. Although some neonatal intensive care units are abandoning the practice of routine GR evaluation, little evidence exists to support the discontinuation or continuation of this practice. This review summarizes the current state of GR evaluation and underlines the need for a scientific basis to either support or refute the routine evaluation of GRs.
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10.
Practice of parenteral nutrition in VLBW and ELBW infants.
Embleton, ND, Simmer, K
World review of nutrition and dietetics. 2014;:177-89
Abstract
Preterm infants have limited nutrient stores at birth, take time to establish enteral feeding, are at risk of accumulating significant nutrient deficits, and frequently suffer poor growth - all risks which are associated with poorer neurodevelopmental outcome. Parenteral nutrition (PN) provides a relatively safe means of meeting nutrient intakes, and is widely used in preterm infants in the initial period after birth. PN is also important for infants who may not tolerate enteral feeds such as those with congenital or acquired gut disorders such as necrotizing enterocolitis (NEC). PN is associated with several short-term benefits, but clear evidence of long-term benefit from controlled trials in neonates is lacking. There are many compositional, practical and risk aspects involved in neonatal PN. In most preterm infants, authorities recommend amino acid intakes approximating to 3.5-4 g/kg/day of protein, lipid intakes of 3-4 g/kg/day and sufficient carbohydrate to meet a total energy intake of 90-110 kcal/kg/day. Where PN is the sole source of nutrition, careful attention to micronutrient requirements is necessary. PN may be administered via peripheral venous access if the osmolality allows, but in many cases requires central venous access. Standardized PN bags may meet the nutrient needs of many preterm infants over the first few days, although restricted fluid intakes mean that many receive inadequate amounts especially of amino acids. PN can be associated with increased rates of bacterial and fungal sepsis, mechanical complications related to venous line placement and miscalculations and errors in manufacture, supply and administration. PN is also associated with metabolic derangements, hepatic dysfunction, and risks contamination with toxins such as aluminum, which enter the solutions during manufacturing. PN must only be administered in units with good quality control, strict asepsis in manufacture and administration and multidisciplinary teams focused on nutrient needs and intakes.