Achievement Of Full Enteral Feeding Research Articles

Laparoscopy-Assisted Percutaneous Cholangiography in Biliary Atresia Diagnosis: Comparison with Open Technique.

Introduction. Biliary atresia is a surgical cause of prolonged jaundice, which needs to be diagnosed with cholangiography that has traditionally been performed via laparotomy. Laparoscopic assistance has lately been introduced to avoid unnecessary laparotomy. We aim to evaluate the benefits of the laparoscopy-assisted cholangiography and compare it to the traditional procedure via laparotomy. Patients and Method. The medical records of the cases who had undergone cholangiography for prolonged jaundice between 2007 and 2014 were analyzed. The patients were grouped according to cholangiography technique (laparotomy/laparoscopy). The laparoscopy and laparotomy groups with patent bile ducts were focused and compared in terms of operation duration, postoperative initiation time of enteral feeding, and full enteral feeding achievement time. Results. Sixty-one infants with prolonged jaundice were evaluated between 2007 and 2014. Among the patients with patent bile ducts, operation duration, postoperative enteral feeding initiation time, and the time to achieve full enteral feeding were shorter in laparoscopy group. Conclusion. Laparoscopic cholangiography is safe and less time-consuming compared to laparotomy, with less postoperative burden. As early age of operation is a very important prognostic factor, laparoscopic evaluation should be an early option in work-up of the infants with prolonged jaundice with direct hyperbilirubinemia, for diagnosis/exclusion of biliary atresia.

Specific formulas for preterm infants, how and when

Both ESPGHAN (2010) and AAP (2012), stated that “all preterm infants should receive human milk” for the many short-term and long termbenefits [1,2]. All kinds of breast milk (fresh by own mother or pastourized by donor) for preterm should be fortified, to gain the recommended requirements. In case of its absence the only alternative is represented by the formulas for preterm infants (PTF). It is not yet definitively established the ideal PTF composition, particularly for ELBW infants. Table 1 shows the main recommendations for nutrients [1-4]. A study compared the use of a soy-based formula (with calcium, phosphorus and vitamin D), with a PTF. Infants taking soy showed lower growth, levels of protein and albumin [5]. ESPGHAN in 2006 concluded that soy-based formulas should not be used in premature infants [6]. The use of hydrolyzed formulas has not shown a preventive role on cow’s milk protein allergy, it has proven helpful in improving food tolerance (acceleration of the intestinal transit time and faster achievement of full enteral feeding), but it has a reduced nutritional value, (especially protein intake) [7-11]. A recent study evaluated the usefulness of a thickened formula in reducing apnea of prematurity GERD-related. The authors conclude that these formulas are not effective in the reduced number of apneas GERD-related [12].

Splanchnic Tissue Oxygenation for Predicting Feeding Tolerance in Preterm Infants.

Feeding intolerance is very frequent in preterm infants, and the development of an early effective biomarker for its prediction could be useful for carrying out a proper feeding strategy. Our aim was to evaluate if the measurement of splanchnic regional oxygenation (rSO2S) and splanchnic fractional oxygen extraction ratio (FOES) using near-infrared spectroscopy (NIRS) is correlated with the time needed to achieve full enteral feeding and if it can predict the development of feeding intolerance. We measured rSO2S and FOES in preterm infants 25 ± 0 to 31 ± 6 weeks of gestational age at 24-72 hours of life during continuous enteral feeding. Linear regression analysis did not evidence any relationship between rSO2S and FOES and the time for achievement of full enteral feeding. Multivariate logistic regression analysis showed that birth weight <1000 g (relative risk [RR], 4.5; 95% confidence interval [CI], 1.23-16.45) and patent ductus arteriosus occurrence (RR, 9.3; 95% CI, 1.31-66.06) increased the risk of developing feeding intolerance in our population. Splanchnic oxygenation and oxygen extraction measured in the first days of life are not correlated with the time needed to achieve full enteral feeding in preterm infants receiving continuous enteral nutrition.

Predictors of full enteral feeding achievement in very low birth weight infants.

BackgroundTo elucidate the role of prenatal, neonatal and early postnatal variables in influencing the achievement of full enteral feeding (FEF) in very low birth weight (VLBW) infants and to determine whether neonatal intensive care units (NICUs) differ in this outcome.MethodsPopulation-based retrospective cohort study using data on 1,864 VLBW infants drawn from the “Emilia-Romagna Perinatal Network” Registry from 2004 to 2009. The outcome of interest was time to FEF achievement. Eleven prenatal, neonatal and early postnatal variables and the study NICUs were selected as potential predictors of time to FEF. Parametric survival analysis was used to model time to FEF as a function of the predictors. Marginal effects were used to obtain adjusted estimates of median time to FEF for specific subgroups of infants.ResultsLower gestational age, exclusive formula feeding, higher CRIB II score, maternal hypertension, cesarean delivery, SGA and PDA predicted delayed FEF. NICUs proved to be heterogeneous in terms of FEF achievement. Newborns with PDA had a 4.2 days longer predicted median time to FEF compared to those without PDA; newborns exclusively formula-fed had a 1.4 days longer time to FEF compared to those fed human milk.ConclusionsThe results of our study suggest that time to FEF is influenced by clinical variables and NICU-specific practices. Knowledge of the variables associated with delayed/earlier FEF achievement could help in improving specific aspects of routine clinical management of VLBW infants and to reduce practice variability.

Practice of enteral nutrition in very low birth weight and extremely low birth weight infants.

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.

Aggressive Nutrition of the Preterm Infant

Nutrition of preterm infants should result in growth similar to that of normally growing fetuses of the same gestational age. Unfortunately, most preterm infants are not fed enough to achieve this objective; as a result they are growth restricted by term gestation. Recent studies have demonstrated that early and enhanced "aggressive" nutrition of preterm infants can reduce postnatal growth failure and improve longer-term outcomes, particularly for the brain and its cognitive functions. When preterm infants are fed more aggressively (earlier onset of intravenous and enteral feeding, earlier achievement of full enteral feeding) cumulative energy and protein deficits are reduced and they consistently regain birth weight sooner, the incidence of necrotizing enterocolitis and late-onset sepsis is unchanged or reduced, and they achieve discharge criteria and go home sooner, with overall shorter hospital stays, and have improved anthropometrics by term gestation. More research is needed, however, to determine optimum feeding of preterm infants, particularly during periods of illness and physiological instability.

Early or Delayed Enteral Feeding for Preterm Growth-Restricted Infants: A Randomized Trial

Growth-restricted preterm infants are at increased risk of developing necrotizing enterocolitis (NEC) and initiation of enteral feeding is frequently delayed. There is no evidence that this delay is beneficial and it might further compromise nutrition and growth. Infants with gestation below 35 weeks, birth weight below the 10th centile, and abnormal antenatal umbilical artery Doppler waveforms were randomly allocated to commence enteral feeds "early," on day 2 after birth, or "late," on day 6. Gradual increase in feeds was guided by a "feeding prescription" with rate of increase the same for both groups. Primary outcomes were time to achieve full enteral feeding sustained for 72 hours and NEC. Four hundred four infants were randomly assigned from 54 hospitals in the United Kingdom and Ireland (202 to each group). Median gestation was 31 weeks. Full, sustained, enteral feeding was achieved at an earlier age in the early group: median age was 18 days compared with 21 days (hazard ratio: 1.36 [95% confidence interval: 1.11-1.67]). There was no evidence of a difference in the incidence of NEC: 18% in the early group and 15% in the late group (relative risk: 1.2 [95% confidence interval: 0.77-1.87]). Early feeding resulted in shorter duration of parenteral nutrition and high-dependency care, lower incidence of cholestatic jaundice, and improved SD score for weight at discharge. Early introduction of enteral feeds in growth-restricted preterm infants results in earlier achievement of full enteral feeding and does not appear to increase the risk of NEC.

Aminoacid-based formula as a rescue strategy for feeding VLBW SGA infants

Whenever breast milk is unavailable, preterm formula is chosen to start and progress enteral feeding in VLBW infants; when these neonates have an associated growth retardation, the achievement of full enteral feeding can be particularly difficult. Consecutively, inborn VLBW neonates with weight centile < 5th, free from major malformations for whom breast milk was not available were enrolled in the study from January 2007 to June 2008. Cases were classified as feeding intolerant after at least 72 h on the basis of a sudden significant increase in gastric residuals and/or an abnormal abdominal examination and fed an Aa-based formula (AAF) with the same schedule. Cases were compared to A) VLBW infants exclusively fed on SPF; and B) themselves before the introduction of AAF. 22 infants were rescued on Aa-based formula; 42 control infants were enrolled. VLBW cases had a shorter number of gastric residual volume > 5 ml/kg at 48 h (3/20) than VLBW controls (15/42), shorter gastric residual volume at 72 h (0.6 ± 1.2) than VLBW controls (0.9 ± 1.5) and shorter residuals/total formula at 72 h (22.4 ± 38.1) than VLBW controls (51.2 ± 104.5) after the introduction of the FE. In the present clinical setting, the use of AAF: • improves feeding tolerance in VLBW cases = 10° of BW; • equalizes the time of parenteral nutrition and the time to reach 150 ml/kg enteral feeding in VLBW cases, compared to VLBW controls, without affecting growth.

Ursodeoxycholic Acid Treatment in Preterm Infants: A Pilot Study for the Prevention of Cholestasis Associated With Total Parenteral Nutrition

In a prospective, double-blind, placebo-controlled trial, the efficacy and safety of ursodeoxycholic acid (UDCA) was evaluated in preterm infants, in terms of its potential impact on fat absorption, advancement of enteral feeding, development of cholestasis, growth, nutritional status, and metabolic status. Although fecal fat excretion slightly decreased and achievement of full enteral feeding was earlier in the UDCA group, these differences were not significant. Interestingly, whereas serum gamma-glutamyl transferase activity increased during the parenteral nutrition period in the placebo group, we observed a constant and significant decrease in the UDCA group. This observation warrants further investigation to determine the utility of prophylactic UDCA in preventing cholestasis in infants with prolonged parenteral nutrition.