Evidence-based Feeding Guidelines Research Articles

Effect of Left and Right Semi-Elevated Side-Lying Positions on Feeding Performance of Preterm Infants

ObjectiveTo determine the effect of right and left semi-elevated side-lying positions on the feeding performance and skills of bottle-fed preterm infants. DesignA single-group, crossover experimental study. SettingsLevel 3 NICU of a training and research hospital in Istanbul. ParticipantsA total of 60 preterm infants born at 24 to 36 6/7 weeks gestation. MethodsWe collected data using an infant information form, feeding observation form, and the Turkish version of the Early Feeding Skills Assessment (EFS-Turkish). For each infant, we collected data for two feeds: one in the right and one in the left semi-elevated side-lying position. ResultsWe found no difference between the right and left semi-elevated side-lying positions in the volume or percentage of food taken (p = .582 and p = .625, respectively), feeding duration (p = .901), or feeding efficiency (p = .423). We observed no significant differences between feedings in the left and right semi-elevated side-lying positions in mean EFS-Turkish total score (p = .251) or subscale scores (p > .05). ConclusionNeonatal nurses can feed preterm infants in both directions of the semi-elevated side-lying position when following evidence-based feeding guidelines.

Concept of neuroprotective NICU

Neurodevelopmental outcomes are of paramount importance for every clinician as the survival rates of term and preterm babies have continued to improve. We aim to provide a framework for developing a Neuroprotective Neonatal Intensive Care Unit (NICU) by describing five main domains below. We achieve this in our NICU by a multidisciplinary team consisting of neonatologists, respiratory therapist, occupational therapist, physiotherapist, social worker, pharmacist, and a dietician. This approach needs to be individualised for each unit based on the resources and services available.I. Neuro assessment: clinical neuro assessment remains the most important tool with strong predictive value for long-term outcomes. It is important to develop other tools of assessment like comfort and pain scoring. We use COMFORTneo scale as a standard of care.1 Neuroimaging is another important factor as part of the assessment. We have a local guideline to decide on the frequency and the timing of the neuroimaging such as cranial ultrasound and MRI.II. Neuroprotection: antenatal magnesium sulphate and antenatal steroids have become an established treatment in most units.2 Interventions like total body cooling have significantly improved the outcomes for babies with hypoxic ischemic injury. One challenge faced in these babies is the ability to provide active cooling during transport when these babies are born outside cooling centres. Optimal nutrition is another important element for the developing brain. We developed neonatal nutritional guidelines in collaboration with the clinical pharmacist and a dietician. Introduction of starter parenteral nutrition bags for out of hours use in line with evidence-based feeding guidelines are known to improve the outcomes. We practice the golden hour protocol for all babies born before 28 weeks gestation and have introduced intraventricular haemorrhage (IVH) prevention bundles3 for the same cohort of babies. Even though individual components of these bundles do not have strong evidence, there is some benefit when these interventions are offered as a bundle. Our care bundle involves midline positioning, using log roll, minimal handling, maintaining normothermia, avoiding IV boluses, and maintaining normal CO2 levels etc.III. Neuromonitoring: tools like amplitude-integrated electroencephalogram (aEEG), near-infrared spectroscopy (NIRS), and onsite MRI are gaining popularity. eEEG should be routinely used in hypoxic ischemic encephalopathy (HIE) babies when available. All team members should be trained in its application and interpretation. NIRS is a developing modality used by only a few units to monitor the cerebral oxygenation. We have recently started to pilot these machines.IV. Neurodevelopment: the environment of the NICU has been shown to affect the developing brain. Strategies should be developed to optimise babies sleeping by reducing lighting and noise levels. We use positioning tools like boundaries and midliners as part of their neurodevelopment.V. Neurointervention: we use therapeutic techniques like auditory, tactile, visual, and vestibular (ATVV) stimulation.4 It is an evidence-based technique used to increase alertness in medically stable preterm infants. We use Prechtl's Qualitative Assessment of General Movements observational tool.5 It is the most predictive tool (98% sensitivity) for detecting cerebral palsy. This helps provide targeted treatment at an earlier stage.

Current practice in the introduction of solid foods for preterm infants.

The present study compared the age of first solid foods in a cohort of preterm infants with term infants and identified factors influencing timing of solid food introduction. Structured interviews on infant feeding practices, growth and medical status at term equivalence and at 3, 6, 9 and 12months corrected postnatal age. The age of solid food introduction was compared between term and preterm infants, and the influence of maternal, infant and milk feeding factors was assessed. This prospective longitudinal study recruited primary carers of preterm and term infants from a regional metropolitan referral hospital in eastern Australia. One hundred and fifty infants (preterm, n85; term, n65). When corrected for prematurity, preterm infants received solid foods before the recommended age for the introduction of solid foods for term infants. Median introduction of solid foods for preterm infants was 14 weeks corrected age (range 12-17 weeks). This was significantly less than 19 weeks (range 17-21 weeks) for term infants (P < 0·001). Lower maternal education and male gender were associated with earlier introduction of solid foods among preterm infants. Preterm infants are introduced to solid foods earlier than recommended for term infants, taking account of their corrected age. Further research is needed to assess any risk or benefit associated with this pattern and thus to develop clear evidence-based feeding guidelines for preterm infants.

Quality improvement initiative to decrease time to full feeds and central line utilization among infants born less than or equal to 32 0/7 weeks through compliance with standardized feeding guidelines.

There are emerging evidences that support more aggressive feeding advancement among preterm infants. Our NICU had conservative feeding advancement guidelines that delayed enteral feeding and prolonged central line use. We aimed to reduce time to full feeds among infants born ≤ 32 0/7 weeks from 12.8 days to 8 days. A multidisciplinary team implemented evidence-based feeding guidelines using quality improvement methods. Days to full enteral feeds, central line days, necrotizing enterocolitis (NEC) rates, and extrauterine growth restriction (EUGR) rates were analyzed. Average days to full enteral feeds decreased from 12.8 to 7.7 days and from 17.5 to 9.1 days for infants born ≤ 32 0/7 weeks and ≤28 0/7 weeks respectively, without significant change in NEC rate. Central line days decreased by 35%. Insignificant improvement in EUGR rate was found. Faster feeding advancement guidelines led to earlier full enteral feeds and reduced central line utilization without increasing complications.

Early feeding patterns among Mexican babies: findings from the 2012 National Health and Nutrition Survey and implications for health and obesity prevention

Feeding practices and dietary factors associated with obesity in young children are now recognized to begin in infancy. Yet little is known about what specific foods and beverages Mexican children are consuming during the rapid dietary changes occurring in the first few years of life. The objective of this study was to describe the transitions in food consumption patterns of Mexican children from birth up to age 4 years and to assess their adherence to feeding guidelines that support growth, development and obesity prevention. We analyzed cross-sectional, 24-hour dietary recall data from a nationally-representative sample of infants ages 0–11.9 months (m) (n = 411), toddlers ages 12–23.9 m (n = 538), and preschoolers ages 24–47.9 m (n = 1108) from the Mexican National Health and Nutrition Survey 2012 (NHNS 2012). The prevalence of foods and beverages was estimated for specific age categories of children useful for examining detailed transitions in food consumption patterns and compared to international feeding guidelines for infants and young children. Few infants were exclusively breastfed (15 % ages 0–3.9 m; 4 % ages 4–5.9 m) and only ~1 % met the recommendation to exclusively breastfeed until at least age 6 m. One to 10 % of infants ages <6 m and 14–38 % of infants ages 6–11 m were fed cow’s milk, a practice not recommended until after age 1 year. Most infants ages 0–3.9 m were meeting the recommendation to delay feeding of complementary foods until age 6 m, but by the age of 4–5.9 m, 9–37 % of infants were fed foods from nearly all of the major food groups. Few infants ages 6–11.9 m received iron-rich foods, (3–4 % iron-fortified infant cereals; 2–18 % meats). By the age of 9 m, more children consumed any type of sweet (75 %) than consumed a distinct portion of fruit (54 %) or vegetable (25 %). Sweetened beverages were fed with an increasing prevalence from 6 to 42 % in infancy, and reached 63 % by age 12 m and 78 % by age 24 m. These data show that dietary patterns begin very early in life and many infants, toddlers and preschoolers in Mexico are not meeting important feeding recommendations aimed at supporting healthy growth, development and obesity prevention. These findings are useful to support the ongoing promotion of evidence-based feeding guidelines for young Mexican children.

A Protocol for Evidence-Based Feeding Guidelines in Critically Ill Adults Does Not Improve Mortality

In critically ill adult patients expected to have an ICU stay greater than 48 hours, the use of an evidence-based protocol for feeding results in improved nutrition but no significant reduction in mortality compared to standard care. Level of evidence: 1+ (RCT with a low risk of bias)

Implementation of an evidence-based feeding guideline did not reduce mortality in intensive care units

Source Citation Doig GS, Simpson F, Finfer S, et al. Effect of evidence-based feeding guidelines on mortality of critically ill adults: a cluster randomized controlled trial. JAMA. 2008;300:2731-41...

Effect of Evidence-Based Feeding Guidelines on Mortality of Critically Ill Adults: A Cluster Randomized Controlled Trial

Effect of Evidence-Based Feeding Guidelines on Mortality of Critically Ill Adults: A Cluster Randomized Controlled Trial

Effect of Evidence-Based Feeding Guidelines on Mortality of Critically Ill Adults

Evidence demonstrates that providing nutritional support to intensive care unit (ICU) patients within 24 hours of ICU admission reduces mortality. However, early feeding is not universally practiced. Changing practice in complex multidisciplinary environments is difficult. Evidence supporting whether guidelines can improve ICU feeding practices and patient outcomes is contradictory. To determine whether evidence-based feeding guidelines, implemented using a multifaceted practice change strategy, improve feeding practices and reduce mortality in ICU patients. Cluster randomized trial in ICUs of 27 community and tertiary hospitals in Australia and New Zealand. Between November 2003 and May 2004, 1118 critically ill adult patients expected to remain in the ICU longer than 2 days were enrolled. All participants completed the study. Intensive care units were randomly assigned to guideline or control groups. Guideline ICUs developed an evidence-based guideline using Browman's Clinical Practice Guideline Development Cycle. A practice-change strategy composed of 18 specific interventions, leveraged by educational outreach visits, was implemented in guideline ICUs. Hospital discharge mortality. Secondary outcomes included ICU and hospital length of stay, organ dysfunction, and feeding process measures. Guideline and control ICUs enrolled 561 and 557 patients, respectively. Guideline ICUs fed patients earlier (0.75 vs 1.37 mean days to enteral nutrition start; difference, -0.62 [95% confidence interval {CI}, -0.82 to -0.36]; P < .001 and 1.04 vs 1.40 mean days to parenteral nutrition start; difference, -0.35 [95% CI, -0.61 to -0.01]; P = .04) and achieved caloric goals more often (6.10 vs 5.02 mean days per 10 fed patient-days; difference, 1.07 [95% CI, 0.12 to 2.22]; P = .03). Guideline and control ICUs did not differ with regard to hospital discharge mortality (28.9% vs 27.4%; difference, 1.4% [95% CI, -6.3% to 12.0%]; P = .75) or to hospital length of stay (24.2 vs 24.3 days; difference, -0.08 [95% CI, -3.8 to 4.4]; P = .97) or ICU length of stay (9.1 vs 9.9 days; difference, -0.86 [95% CI, -2.6 to 1.3]; P = .42). Using a multifaceted practice change strategy, ICUs successfully developed and introduced an evidence-based nutritional support guideline that promoted earlier feeding and greater nutritional adequacy. However, use of the guideline did not improve clinical outcomes. Trial Registration anzctr.org.au Identifier: ACTRN12608000407392.

Assessment and Management Considerations for Oral Feeding of the Premature Infant on the Neonatal Intensive Care Unit

Assessment and Management Considerations for Oral Feeding of the Premature Infant on the Neonatal Intensive Care Unit