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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.
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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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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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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Economic benefits and costs of human milk feedings: a strategy to reduce the risk of prematurity-related morbidities in very-low-birth-weight infants.
Johnson, TJ, Patel, AL, Bigger, HR, Engstrom, JL, Meier, PP
Advances in nutrition (Bethesda, Md.). 2014;(2):207-12
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Abstract
Infants born at very low birth weight (VLBW; birth weight <1500 g) are at high risk of mortality and are some of the most expensive patients in the hospital. Additionally, VLBW infants are susceptible to prematurity-related morbidities, including late-onset sepsis, bronchopulmonary dysplasia (BPD), necrotizing enterocolitis, and retinopathy of prematurity, which have short- and long-term economic consequences. The incremental cost of these morbidities during the neonatal intensive care unit (NICU) hospitalization is high, ranging from $10,055 (in 2009 US$) for late-onset sepsis to $31,565 for BPD. Human milk has been shown to reduce both the incidence and severity of some of these morbidities and, therefore, has an indirect impact on the cost of the NICU hospitalization. Furthermore, human milk may also directly reduce NICU hospitalization costs, independent of the indirect impact on the incidence and/or severity of these morbidities. Although there is an economic cost to both the mother and institution for providing human milk during the NICU hospitalization, these costs are relatively low. This review describes the total cost of the initial NICU hospitalization, the incremental cost associated with these prematurity-related morbidities, and the incremental benefits and costs of human milk feedings during critical periods of the NICU hospitalization as a strategy to reduce the incidence and severity of these morbidities.
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Breast milk-acquired cytomegalovirus infection and disease in VLBW and premature infants.
Lanzieri, TM, Dollard, SC, Josephson, CD, Schmid, DS, Bialek, SR
Pediatrics. 2013;(6):e1937-45
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Abstract
BACKGROUND Very low birth weight (VLBW) and premature infants are at risk for developing postnatal cytomegalovirus (CMV) disease, including CMV-related sepsis-like syndrome (CMV-SLS) for which estimates [corrected] in the United States are lacking. METHODS We performed a systematic review and meta-analysis to estimate the pooled proportions (and 95% confidence intervals) of VLBW and premature infants born to CMV-seropositive women with breast milk-acquired CMV infection and CMV-SLS. We combined these proportions with population-based rates of CMV seropositivity, breast milk feeding, VLBW, and prematurity to estimate annual rates of breast milk-acquired CMV infection and CMV-SLS in the United States. RESULTS In our meta-analysis, among 299 infants fed untreated breast milk, we estimated 19% (11%-32%) acquired CMV infection and 4% (2%-7%) developed CMV-SLS. Assuming these proportions, we estimated a rate of breast milk-acquired CMV infection among VLBW and premature infants in the United States of 6.5% (3.7%-10.9%) and 1.4% (0.7%-2.4%) of CMV-SLS, corresponding to 600 infants with CMV-SLS in 2008. Among 212 infants fed frozen breast milk, our meta-analysis proportions were 13% (7%-24%) for infection and 5% (2%-12%) for CMV-SLS, yielding slightly lower rates of breast milk-acquired CMV infection (4.4%; 2.4%-8.2%) but similar rates of CMV-SLS (1.7%; 0.7%-4.1%). CONCLUSIONS Breast milk-acquired CMV infection presenting with CMV-SLS is relatively rare. Prospective studies to better define the burden of disease are needed to refine guidelines for feeding breast milk from CMV-seropositive mothers to VLBW and premature infants.
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Timing of nutritional interventions in very-low-birth-weight infants: optimal neurodevelopment compared with the onset of the metabolic syndrome.
Lafeber, HN, van de Lagemaat, M, Rotteveel, J, van Weissenbruch, M
The American journal of clinical nutrition. 2013;(2):556S-60S
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Abstract
Recent nutritional research in very-low-birth-weight (VLBW) infants is focused on the prevention of protein malnutrition during the first postnatal weeks. At this early age, nutritional protein fortification depends on amino acid infusion via a central vein because of the immature gastrointestinal tract. In 2010 new guidelines on nutrition were proposed by the European Society of Paediatric Gastroenterology, Hepatology, and Nutrition nutrition committee. In particular, the relative increase in the protein fraction in the nutrition of these infants aims to prevent early postnatal weight loss, to prevent morbidity, and to stimulate neurodevelopment. On the other hand, an increasing number of follow-up studies in VLBW infants indicate that, in particular, those infants who show rapid growth after preterm birth are at risk of metabolic consequences and cardiovascular disease later in life. In this review, we describe the quest to develop a customized diet that offers optimal nutrition at several time points of growth and development during the first year of life. This diet should prevent early malnutrition, enhance neurodevelopment, and limit the increase in total body fat during the first 6 mo. We question whether one type of early diet suffices for normal neurodevelopment with a normal body composition in later life or whether we need several types of diet at various stages of development.
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Does human milk reduce infection rates in preterm infants? A systematic review.
de Silva, A, Jones, PW, Spencer, SA
Archives of disease in childhood. Fetal and neonatal edition. 2004;(6):F509-13
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Abstract
One of the reasons for advocating human milk (HM) feeding for preterm infants is the belief that this provides the infant with a degree of protection from infection. Providing fresh HM for such infants is challenging for mothers and staff, and consequently it is important that its benefits are rigorously evaluated. Therefore a systematic review was undertaken to assess all publications concerned with human milk feeding and infection in very low birth weight (VLBW) preterm infants. Nine studies--six cohort and three randomised controlled trials (RCT)--were assessed using predefined criteria. Methodological problems included poor study design, inadequate sample size, failure to adjust for confounding variables, and inadequate definitions of HM feeding and outcome measures. In conclusion, the advantage of HM in preventing infection in preterm, (VLBW) infants is not proven by the existing studies. Recommendations are made regarding the methodology required for further study of this important topic.