Feeding Intolerance Research Articles

Influence of gastric residual assessment in preterm neonates on time to achieve enteral feeding (the GRASS trial)—Multi-centre, assessor-blinded randomised clinical trial

PurposeGastric residual measurement is routinely performed in premature infants prior to feeding despite a lack of evidence of benefit. We aimed to evaluate if the exclusion of routine gastric residual measurement and evaluation has an impact on the time taken to achieve full enteral feeding in preterm neonates.MethodsInternational multi-centre randomised controlled trial. Clinically stable, appropriate for gestational age infants between 26+0 and 30+6 weeks of gestation and less than 1.5 kg birth weight were eligible. Infants were randomised to the intervention arm (no monitoring of gastric aspirates) or control arm (routine care). Primary outcome was the achievement of enteral feeds of 100 ml/kg/day by day 5 of life.ResultsNinety-five infants were recruited with 88 included in an intention-to-treat analysis, 45 in the intervention arm and 43 in the control arm. There was no imbalance in baseline characteristics. Thirty-three (73.3%) infants in the intervention group and 32 infants (74.4%) in the control group reached full feeds by day 5 of life (p = 0.91) with no difference in median time to full feeds. There were no statistically significant differences in survival or the major morbidities of prematurity. Conclusion: There was no difference in time to attainment of enteral feeds of 100 ml/kg/day in premature infants when gastric residuals were not monitored. In the absence of a clinical benefit to routine monitoring, it may be appropriate to discontinue this practice and only monitor residuals when clinical concern of feeding intolerance or gastrointestinal pathology arises in this group of patients.Trial registration: NCT03111329—https://clinicaltrials.gov/. Registered 06/04/2017.What is Known:• Previous randomized trials have shown little benefit to the performance of routine assessment of gastric residuals in preterm infants. Despite this, they continue to be performed due to concerns from observational data regarding development of NEC. Meta-analysis to date has failed to answer the question regarding NEC.What is New:• In very low birth weight infants who are fed using modern feeding practice of faster feed advancement, to minimize use of central access and parenteral nutrition, exclusion of routine checks of gastric residuals did not increase the proportion of infants reaching full enteral feeds by day 5. No harm was seen when residual checks were not performed.• In the absence of a clinical benefit to the routine performance of gastric residuals in very low birth weight infants, it may be appropriate to discontinue their use and instead check residuals when clinical concern of pathology arises.

The Use of a Novel Donkey Milk-Derived Human Milk Fortified in the Neonatal Period Had No Effect on the Frequency of Allergic Manifestations During the First Years of Life: The "Fortilat Trial" Follow-Up.

Background: Since human milk contents does not meet the high need of very low birth weight infants, fortification of breast milk is a standard practice for this population. As donkey milk has been long considered for children allergic to cow's milk proteins due to its low allergic properties, a new donkey milk-derived fortifier (DF) has been recently evaluated as a valid alternative to bovine milk-derived fortifier (BF). It seems to improve feeding tolerance when compared with standard BF, with similar neurodevelopmental and auxological outcome at 18 months of age. The aim of this study is to evaluate the development of allergic manifestations occurring in the population of the "Fortilat Trial" at 6-8 years of age. Methods: Allergic manifestations were assessed by an ad hoc questionnaire administered to families. The occurrence of asthma, allergic rhinitis and oculorhinitis, rashes and atopic dermatitis, food allergies, accesses to an emergency department for allergic reactions, and the need of antihistamine have been investigated. Results: In total, 113 infants were enrolled in the study (BF arm: n = 60, DF arm: n = 53). No difference in risk was observed between the two groups for all the considered outcomes. In conclusion, our data suggest that DF does not impact the development of allergic manifestations in the first years of life. Clinical Trial Registration number: ISRCT N70022881.

Effect of novel human milk oligosaccharides-based human milk fortifier containing lactoferrin, docosahexaenoic acid, and arachidonic acid on the growth of preterm infants with birth weight of 700–1800 g

Background: Premature infants with low birth weight are at risk of growth failure and neurodevelopmental impairment. Human milk oligosaccharides (HMOs) are bioactive components of human milk that may enhance growth and development. The novel HMO-based human milk fortifier (HMoF), which also contains lactoferrin, docosahexaenoic acid (DHA), and arachidonic acid (ARA), can help provide a safer nutritional option for the growth of premature infants. Materials and Methods: We conducted a non-comparative observational study using data from multiple centers that used novel HMO-based HMF (HMoF) in premature infants (n=14) with birth weights of 700–1800 g. The primary outcome of the study was to assess tolerability (in terms of feed tolerance), and secondary outcomes included growth outcomes defined by weight, length, and head circumference during the stay in the NICU and at discharge. Results: A cohort consisting of 14 infants with a mean gestational age of 30.21±2.04 weeks and a birth weight of 1246.36±39.98 g comprised the study. During the study period, incidences of feed interruptions due to feed intolerability were nil, and no infant presented with any signs of adverse effects. The novel HMO-based HMF (HMoF)-fed infant cohort had a mean weight gain of 21.89±5.23 g/day, a mean length gain of 1.01±0.48 cm/week, and mean head circumference gain of 0.89±0.32 cm/week. The mean growth velocity recorded was 16.03±1.73 g/kg/day. Conclusions: Novel HMO-based HMF (HMoF) containing lactoferrin, DHA, and ARA demonstrated acceptable feed tolerance and weight gain without any clinically significant adverse effects. Data indicates that the novel HMoF containing lactoferrin, DHA, and ARA is a safe option for supporting the growth of preterm babies. However, further studies are needed to compare novel HMO-based HMF (HMoF) with standard HMF in a randomized controlled trial.

The Association between Delayed Gut Microbiota Maturity in Pre-Term Infants and the Feeding Intolerance-A Pilot Study.

This study compared gut (fecal) microbiota profiles between pre-term and full-term infants, assuming that pre-term infants without feeding intolerance would have gut microbiota similar to those of full-term infants. A total of 13 pre-term infants (gestational age < 37 weeks, birthweight ≤ 2500 g) and 10 full-term infants were included. The pre-term infants were assigned to the feeding tolerance (FT) group (n = 7) if their daily intake exceeded 100 mL/kg/day at two weeks after birth, or the feeding intolerance (FI) group (n = 6). Microbial DNA from weekly fecal samples was analyzed. The microbiota profiles of the pre-term infants and full-term infants were significantly different (p = 0.0001), as well as the FT and FI groups (p = 0.0009). The full-term group had more diversity, with higher concentrations of facultative anaerobes such as Bifidobacteriaceae and Lactobacteriaceae. The FT group's gut microbiota matured over four weeks, with higher levels of digestion-related bacteria, while the FI group had more pathogens. In the FI group, a significant difference was observed between the first and second weeks, with no significant differences noted between the first week and the third or fourth weeks. The delay in the development of the pre-term infants' gut microbiota may be associated with the FI.

Does Early Fortification of Human Milk Decrease Time to Regain Birth Weight as Compared to Late Fortification Among Preterm Infants? - A Randomized Controlled Trial.

To compare the duration required to regain birth weight following early fortification of human milk vs. late fortification among preterm infants. This randomized controlled trial included hemodynamically stable 120 preterm infants (≤32 wk of gestation). The intervention and comparator groups received standard fortification with human milk fortifier when enteral feeds reached 30ml/kg/d (early fortification) and 80ml/kg/d (late fortification) respectively. Neonates in both the groups received feed increments as per standard NICU protocol. Anthropometric measurements (weight, length, and head circumference) at birth and during postnatal follow-up were done following standard precautions and plotted on the sex-specific Fenton growth charts. Primary outcome was the mean duration required to regain birth weight. Secondary outcomes included weight gain velocity, linear growth, increase in head circumference and occurrence of sepsis, feed intolerance and necrotizing enterocolitis. Preterm neonates who received early fortification regained birth weight earlier compared to those in the late fortification group (10.13 ± 2.90 vs. 11.26 ± 3.06, p <0.05). The weight gain velocity, linear growth and increase in head circumference were better in the early fortification group. There was no increased risk of culture proven sepsis, feed intolerance and necrotizing enterocolitis in the early fortification group compared to late fortification. Standard fortification with human milk fortifier when enteral feeds reach 30ml/kg/d helps preterm neonates regain birth weight earlier. Early fortification is well tolerated and safe for the population studied.

The effects of gastrojejunostomy tube placement on pulmonary and gastrointestinal complications following spinal fusion for neuromuscular scoliosis.

To evaluate whether preoperative conversion from a gastrostomy tube (G-tube) to a gastrojejunostomy tube (GJ-tube) decreases short-term postoperative aspiration pneumonia and gastrointestinal complications in children with neuromuscular scoliosis. We conducted a retrospective chart review from January 2006 to October 2021 of pediatric patients who had neuromuscular scoliosis and were fed with a G-tube before spinal fusion. Eligible patients were divided into two groups based on whether they were converted to a GJ-tube preoperatively. Preoperative characteristics and 30-day postoperative outcomes were compared between groups using Chi-square tests. Of 261 eligible patients, 205 were converted to a GJ-tube, while 56 underwent spinal fusion with a G-tube. Common complications following G-tube to GJ-tube conversion were feeding intolerance (25.2%), GJ-tube malfunction (17.7%), and at least one episode of vomiting (17.4%). Within 30 days of discharge, 12.5% of GJ-tube patients and 11.5% of G-tube patients experienced aspiration pneumonia (P = 0.85). The GJ-tube group received postoperative tube feeds 7 hours earlier than the G-tube group on average (51.6 h vs. 44.5 h, P = 0.02). Within 30 days of discharge, one (0.5%) patient from the GJ-tube group died of gastrointestinal complications unrelated to conversion and two (3.6%) patients in the G-tube group died from aspiration pneumonia (P = 0.12). Results suggest that there were no appreciable differences in outcomes between patients converted to a GJ-tube preoperatively compared to those who continued to use a G-tube. However, preoperative characteristics indicate that a higher number of complex patients were converted to a GJ-tube, indicating potential selection bias in this retrospective sample. Level of evidence: Level III.

Neonatal lupus erythematosus as a rare trigger of gastrointestinal involvement in neonates

Cutaneous and cardiac involvement in neonatal lupus erythematosus (NLE) has been extensively studied; however, gastrointestinal system involvement (GSI) remains unexplored. This study aimed to investigate the clinical features of GSI in patients with NLE with a particular focus on feeding intolerance (FI) and diarrhea. We conducted a retrospective analysis of the clinical data of patients diagnosed with NLE at the Children’s Hospital of Soochow University between 2011 and 2022. In this study, of 39 patients diagnosed with NLE, 27 presented with GSI. 9 patients who presented with FI or diarrhea as the primary manifestation were positive for anti-SSA antibody, and 5 were dual positive for anti-SSA and anti-SSB antibodies. Among the mothers of the NLE patients with GSI, 18 had systemic lupus erythematosus, 3 had Sjogren’s syndrome, 2 had mixed connective tissue disease, and one each had autoantibody abnormalities and photosensitivity symptoms; 4 mothers denied having any autoimmune disease. In this study, 69.23% of patients with NLE exhibited GSI, which was linked to hypocomplementemia and anti-SSA antibodies. Thus, clinicians should remain vigilant for NLE in neonates, particularly when accompanied with rash and other organ dysfunction and when the high-risk factors of FI and diarrhea have been excluded.

A randomized control study on the effect of probiotics on feed tolerance in very low birth weight neonates

Background: Probiotics are live microbial supplements that increase feed tolerance, colonize the gut of these newborns with beneficial flora, and promote growth in these infants. Aims and Objectives: This study was planned to compare the role of probiotics in low birth weight (LBW) infants in the time taken to reach full feeds, episodes of feed intolerance, weight gain, duration of hospital stay, incidence of necrotizing enterocolitis (NEC) stage 2 or more, and morbidity and mortality during hospital stay. Materials and Methods: This interventional two-arm blinded randomized control study was conducted in Thoothukudi Government Medical College Hospital, Thoothukudi, from November 2019 to October 2020. The selected sample of babies was randomly divided into two groups, the probiotic and the no-probiotic group. Bifidobacterium breve M-16 was administered to infants in the probiotic group at a dose of 0.5 g/day once a day in breast milk. Only breast milk was used to feed babies in the no-probiotic group. Results: The time to reach full enteral feed was shorter in the probiotic group (9.21±1.74 days) than in the no-probiotic group (12.43±3.74 days). Better feed tolerance (12%) was seen in the probiotic group than in the no-probiotic (44%) group. A low incidence of sepsis (12%) was seen in the probiotic group than in the non-probiotic group (40%). A lesser duration of hospital stay (10.42±1.77 days) was seen in the probiotic group than in the probiotic group (13.78±4.18 days). Conclusion: Very LBW neonates who received probiotic supplements along with their feeds have shorter times to reach full feeds, greater feed tolerance, lower rates of sepsis, and shorter mean hospital stays.

662 - Electrogastrography mean power ratio as an objective measure of feeding intolerance in preterm infants

662 - Electrogastrography mean power ratio as an objective measure of feeding intolerance in preterm infants

Deimplementation of Gastric Residual Volume Monitoring to Enhance Patient Nutrition.

Routine gastric residual volume monitoring remains common in nursing practice. However, current evidence supports using a focused nursing assessment to identify signs and symptoms of enteral feeding intolerance such as abdominal pain, abdominal distension, and vomiting. At the author's institution, nurses and other clinicians began reporting inconsistencies in gastric residual volume monitoring along with frequent interruptions in the delivery of enteral nutrition. The quality improvement project included patients in the medical intensive care unit receiving enteral nutrition. Gastric residual volume monitoring was eliminated. Instead, enteral nutrition was suspended on the basis of signs and symptoms of enteral feeding intolerance. Multimodal education was provided to nurses, nurse practitioners, and physicians caring for these patients. Formative evaluation occurred via staff rounds, summative evaluation occurred through a staff survey, and nutritional adequacy was evaluated by tracking patient weight. The 6-week project included 37 patients on the medical intensive care unit service. Of these patients, 28 gained weight; the mean change in weight was +6.2%. The practice change was well perceived by staff and is now an established part of care for any patient receiving enteral feedings at the study hospital. The deimplementation of routine gastric residual volume monitoring is supported by evidence. Use of a focused gastrointestinal nursing assessment to identify enteral feeding intolerance is safe, feasible, and effective and improves nutrition delivery and nurses' workflow.

Using a new human milk fortifier to optimize human milk feeding among very preterm and/or very low birth weight infants: a multicenter study in China

BackgroundHuman milk fortifier (HMF) composition has been optimized recently. But clinical evidence of its safety and efficacy is limited in Chinese population. The aim of this study was to evaluate effects of a new HMF in growth, nutritional status, feeding intolerance, and major morbidities among very preterm (VPT) or very low birth weight (VLBW) infants in China.MethodsVPT/VLBW infants admitted from March 2020 to April 2021 were prospectively included in the experimental (new HMF, nHMF) group, who received a new powdered HMF as a breast milk feeding supplement during hospitalization. Infants in the control group (cHMF) admitted from January 2018 to December 2019, were retrospective included, and matched with nHMF group infants for gestational age and birth weight. They received other kinds of commercially available HMFs. Weight gain velocity, concentrations of nutritional biomarkers, incidence of major morbidities, and measures of feeding intolerance were compared between the two groups.ResultsDemographic and clinical characteristics of infants in nHMF and cHMF groups were comparable. Weight gain velocity had no significant difference between the nHMF (14.0 ± 3.5 g/kg/d) and the cHMF group (14.2 ± 3.8 g/kg/d; P = 0.46). Incidence of morbidities, including necrotizing enterocolitis, bronchopulmonary dysplasia, retinopathy of prematurity, culture-confirmed sepsis, and feeding intolerance during hospitalization between nHMF and cHMF, were similar (all P-values > 0.05). The time to achieve full enteral feeding [13.5 (10, 21) days] in the nHMF group was significantly shorter than that in the cHMF group [17 (12, 23) days, HR = 0.67, 95%CI: 0.49, 0.92; P = 0.01]. Compared with cHMF group, the decrease of blood urea nitrogen level over time in nHMF group was smaller (β = 0.6, 95%CI:0.1, 1.0; P = 0.01).ConclusionsThe new HMF can promote growth of preterm infants effectively without increasing the incidence of major morbidity and feeding intolerance. It can be used feasible in Chinese VPT/VLBW infants.Trial registrationThis study was registered on ClinicalTrials.gov (NCT04283799).

Ccr2-dependent monocytes exacerbate intestinal inflammation and modulate gut serotonergic signaling following traumatic brain injury.

Traumatic brain injury (TBI) leads to acute gastrointestinal dysfunction and mucosal damage, resulting in feeding intolerance. C-C motif chemokine receptor 2 (Ccr2 + ) monocytes are crucial immune cells that regulate the gut's inflammatory response via the brain-gut axis. Using Ccr2 ko mice, we investigated the intricate interplay between these cells to better elucidate the role of systemic inflammation after TBI. A murine-controlled cortical impact model was used, and results were analyzed on postinjury days 1 and 3. The experimental groups included (1) sham C57Bl/6 wild type (WT), (2) TBI WT, (3) sham Ccr2 ko , and (4) TBI Ccr2 ko . Mice were euthanized on postinjury days 1 and 3 to harvest the ileum and study intestinal dysfunction and serotonergic signaling using a combination of quantitative real-time polymerase chain reaction, immunohistochemistry, fluorescein isothiocyanate-dextran motility assays, and flow cytometry. Student's t test and one-way analysis of variance were used for statistical analysis, with significance achieved when p < 0.05. Traumatic brain injury resulted in severe dysfunction and dysmotility of the small intestine in WT mice as established by significant upregulation of inflammatory cytokines iNOS , Lcn2 , TNFα , and IL1β and the innate immunity receptor toll-like receptor 4 ( Tlr4 ). This was accompanied by disruption of genes related to serotonin synthesis and degradation. Notably, Ccr2 ko mice subjected to TBI showed substantial improvements in intestinal pathology. Traumatic brain injury Ccr2 ko groups demonstrated reduced expression of inflammatory mediators ( iNOS , Lcn2 , IL1β , and Tlr4 ) and improvement in serotonin synthesis genes, including tryptophan hydroxylase 1 ( Tph1 ) and dopa decarboxylase ( Ddc ). Our study reveals a critical role for Ccr2 + monocytes in modulating intestinal homeostasis after TBI. Ccr2 + monocytes aggravate intestinal inflammation and alter gut-derived serotonergic signaling. Therefore, targeting Ccr2 + monocyte-dependent responses could provide a better understanding of TBI-induced gut inflammation. Further studies are required to elucidate the impact of these changes on brain neuroinflammation and cognitive outcomes.

Small intestinal CaSR-dependent and CaSR-independent protein sensing regulates feeding and glucose tolerance in rats.

Proteins activate small intestinal calcium sensing receptor (CaSR) and/or peptide transporter 1 (PepT1) to increase hormone secretion1-8, but the effect of small intestinal protein sensing and the mechanistic potential of CaSR and/or PepT1 in feeding and glucose regulation remain inconclusive. Here we show that, in male rats, CaSR in the upper small intestine is required for casein infusion to increase glucose tolerance and GLP1 and GIP secretion, which was also dependent on PepT1 (ref. 9). PepT1, but not CaSR, is required for casein infusion to lower feeding. Upper small intestine casein sensing fails to regulate feeding, but not glucose tolerance, in high-fat-fed rats with decreased PepT1 but increased CaSR expression. In the ileum, a CaSR-dependent but PepT1-independent pathway is required for casein infusion to lower feeding and increase glucose tolerance in chow-fed rats, in parallel with increased PYY and GLP1 release, respectively. High fat decreases ileal CaSR expression and disrupts casein sensing on feeding but not on glucose control, suggesting an ileal CaSR-independent, glucose-regulatory pathway. In summary, we discover small intestinal CaSR- and PepT1-dependent and -independent protein sensing mechanisms that regulate gut hormone release, feeding and glucose tolerance. Our findings highlight the potential of targeting small intestinal CaSR and/or PepT1 to regulate feeding and glucose tolerance.

Feeding Intolerance in Critically Ill Patients with Enteral Nutrition: A Meta-Analysis and Systematic Review.

Feeding intolerance is a common yet serious complication in critically ill patients undergoing enteral nutrition. We aimed to conduct a meta-analysis to evaluate the risk factors of feeding intolerance in critically ill patients undergoing enteral nutrition, to provide insights to the clinical enteral nutrition treatment and care. Two researchers systematically searched PubMed, Medline, Web of Science, Cochrane Library, Chinanews. com, Wanfang and Weipu databases about the studies on the risk factors of feeding intolerance in severe patients with enteral nutrition up to August 15, 2023. Literature screening, data extraction and quality evaluation were carried out independently by two researchers, and Meta analysis was carried out with RevMan 5.3 software and Stata 15.0 software. 18 studies involving 5564 enteral nutrition patients were included. The results of meta-analyses showed that age < 2 years old, age > 60 years old, APACHE II score ≥ 20, Hypokalemia, starting time of enteral nutrition > 72 hours, no dietary fiber, intra-abdominal pressure > 15mmHg, central venous pressure > 10cmH2O and mechanical ventilation were the risk factors of feeding intolerance in critically ill patients undergoing EN (all P<0.05). No publication biases were found amongst the included studies. The incidence of feeding intolerance in critically ill patients undergoing enteral nutrition is high, and there are many influencing factors. Clinical medical workers should take effective preventive measures according to the risk and protective factors of patients to reduce the incidence of feeding intolerance and improve the prognosis of patients.

Development and validation of a nomogram for predicting 28-day mortality in critically ill patients with acute gastrointestinal injury: prospective observational study.

Developing and validating a clinical prediction nomogram of 28-day mortality in critically ill patients with acute gastrointestinal injury (AGI). Firstly, the construction of a clinical prediction model was developed using data obtained from a prospective observational study from May 2023 to April 2024. Then, data from a prospective multicenter observational study conducted in the intensive care units of 12 teaching hospitals in 2014 were utilized to independently and externally validate the clinical prediction model developed in the first part. We first screened the covariates of the development cohort by univariate cox regression, and then carried out cox regression analysis on the development cohort by backward stepwise regression to determine the optimal fitting model. Subsequently, a nomogram was derived from this model. A total of 1102 and 379 patients, 28-day mortality occurred in 20.3% and 15.8% of patients respectively, were included in the development and validation cohort, respectively. We developed a nomogram in critically ill patients with AGI and the AGI grade, APACHE II score, Mechanical ventilation (MV), Feeding intolerance (FI) and daily calorie intake (DCI) in 72 h, were independent predictors of 28-day mortality, with the OR of the AGI grade was 1.910 (95% CI, 1.588-2.298; P < 0.001), the OR of APACHE II score was 1.099 (95% CI, 1.069-1.130; P < 0.001), the OR of MV was 1.880 (95% CI, 1.215-2.911; P = 0.005), the OR of FI was 3.453 (95% CI, 2.414-4.939; P < 0.001) and the DCI > 0.7 or < 0.5 of calorie target is associated with increased 28-day mortality, with OR of 1.566 (95% CI, 1.024-2.395; P = 0.039) and 1.769 (95% CI, 1.170-2.674; P = 0.007), respectively. Independent external validation of the prediction model was performed. This model has good discrimination and calibration. The DCA and CIC also validated the good clinical utility of the nomogram. The prediction of 28-day mortality can be conveniently facilitated by the nomogram that integrates AGI grade, APACHE II score, MV, FI and DCI in 72 h in critically ill patients with AGI.

Feeding Intolerance after Pediatric Cardiac Surgery Associated with Dysbiosis, Barrier Dysfunction, and Reduced Fatty Acids

Feeding Intolerance after Pediatric Cardiac Surgery Associated with Dysbiosis, Barrier Dysfunction, and Reduced Fatty Acids

Impact of resuscitative endovascular balloon occlusion of the aorta on gastrointestinal function with a matched cohort study

BackgroundResuscitative endovascular balloon occlusion of the aorta (REBOA) can temporarily control arterial hemorrhage in torso trauma; however, the abdominal visceral blood flow is also blocked by REBOA. The aim of...

Gastrointestinal Tolerance of Formula-Fed Infants During the Immediate Postnatal Period in Saudi Arabia: An Observational Study.

Objective. Feeding intolerance during the early postnatal period can be distressing for families. To assess this, infants (n = 150) of mothers who had previously decided to exclusively or partially formula feed were enrolled ≤24 hours after birth. Methods. Infants were fed with a single ready-to-feed, 100% partially hydrolyzed whey protein-based formula until discharge, in accordance with standard hospital practice. Parents recorded daily the presence/severity of gastrointestinal (GI) symptoms/behaviors, rated from 0 (never) to 5 (always). A validated questionnaire was completed at discharge to evaluate symptoms of GI discomfort; scores can range from 0 to ~140 (lower scores indicate fewer symptoms). Results. Mean ± SD daily scores ranged from 0.12 ± 0.40 (fussiness/irritability) to 1.26 ± 0.90 (spitting up), indicating that GI symptoms/behaviors occurred, on average, "never" or "almost never." Mean GI discomfort scores were also very low (9.9 ± 7.4). Conclusion. These results indicate that the ready-to-feed formula was very well accepted and well tolerated during this period among healthy newborns in Saudi Arabia.

Energy Dense Feeding in Premature Infants and Its’ Associated Outcomes

COVID-19 infection in pregnant mothers is associated with higher risk of intrauterine growth retardation and premature births. Very low birth weight infants are more susceptible to neurodevelopmental and chronic respiratory problems. An infant delivered at 33 weeks via caesarean section to a COVID-19 Stage 5A positive mother, weighing 1.43kg at birth. She was kept nil by mouth with parenteral nutrition (PN) support since day five of life until referred to dietitian on day 22 of life for enteral nutrition (EN) establishment. Feeding was administered intermittently via oro-gastric Ryle’s Tube. She was kept under non-invasive ventilation (NIV) mode and had difficulty in weaning from ventilation, leading to slow feeding progress. Initially, enteral trophic feeding was administered using premature infant formula fortified with modular products. In the later stage of feeding, modular products were tapered off and the formula was concentrated. Frequency of bowel output when using fortified formula is lesser compared to when using concentrated and supplemented formula. There is no significant difference in renal profile observed in both stages of feeding. Increasing energy intake using easily digestible sources is preferable as opposed to concentrating feeds even further due to concerns about osmolality and excess administration of other solutes. Intermittent bolus feeding mode may have an effect on dependency on oxygen since intermittent feeds can decrease tidal volume, minute ventilation and dynamic compliance. Additional research is necessary to establish optimal caloric density and nutritional compositions of feedings, feeding mechanisms and its’ effect on feeding tolerance.

Successful treatment of dumping syndrome with diazoxide in an infant with hypoplastic left heart syndrome.

Dumping syndrome is a rare but potentially serious condition that causes inappropriate postprandial hyperinsulinemia leading to hypoglycemia in children following gastrointestinal surgeries. While dietary modifications are often the first line of treatment, severe cases may require pharmacological intervention to prevent severe hypoglycemia. We present a case of successful treatment of dumping syndrome with diazoxide. A 2-month-old infant with left hypoplastic heart syndrome who underwent single ventricle palliation pathway and developed feeding intolerance that required Nissen fundoplication. Postprandial hypoglycemia was detected following the procedure, with glucose level down to 12 mg/dL, and the diagnosis of dumping syndrome was established. The patient was successfully managed with diazoxide, which effectively resolved postprandial hypoglycemia without any major adverse events. The patient was eventfully weaned off the medication at the age of 5 months. This case highlights the potential role of diazoxide in the management of pediatric patients with postprandial hyperinsulinemic hypoglycemia secondary to dumping syndrome. Dumping syndrome is a possible complication of gastrointestinal surgeries and should be suspected in children with abnormal glucose levels. Postprandial hyperglycemia should be monitored closely for significant subsequent hypoglycemia. Diazoxide might be considered as part of the treatment plan for dumping syndrome.