Initial Enteral Feeding Research Articles

Enteral Feeding for Moderately Premature and Low Birth Weight Infants: A Single-Center Retrospective Observational Cohort Study.

Controversy exists in clinical practice regarding optimal initial enteral feeding (EF) for moderately premature and low birth weight (BW) infants. We included 96 infants stratified into 3 groups (I: 1600-1799 g [n = 22]; II: 1800-1999 g [n = 42]; III: 2000-2200 g [n = 32]). The protocol recommended starting with minimal EF (MEF) in infants weighing <1800 g. On the first day of life, 5% of the infants in group I did not follow the protocol mandating MEF, but started with exclusive EF instead, compared to 36% and 44% of the infants in groups II and III, respectively. The median number of days until exclusive EF was achieved was 5 days longer for infants receiving MEF than for infants who had received normal portions of EF from birth onward. We observed no significant differences in feeding-related complications. We advocate omitting MEF in moderately premature infants with a BW of 1600 g or higher.

Long-term evolution of neuroendocrine cell hyperplasia of infancy: the FRENCHI findings.

Only few studies report long-term evolution of patients with neuroendocrine cell hyperplasia of infancy (NEHI). We report data from a 54-patient cohort followed up in the French network for rare respiratory diseases (RespiRare). Demographic characteristics and respiratory and nutritional evolution were collected at the time of the patient's last scheduled visit. The mean duration of follow-up was 68months (5months to 18years). Fifteen patients (27.8%) were considered clinically cured. During follow-up, hospitalizations for wheezy exacerbations were reported in 35 patients (55%), and asthma diagnosed in 20 (37%). Chest CT scan improvement was noted in 25/44 (56.8%). Spirometry showed a persistent obstructive syndrome in 8/27 (29.6%). A sleep disorder was rare (2/36, 5.5%). Oxygen weaning occurred in 28 of the 45 patients initially treated (62.2%) and was age-dependent (35.7% under 2years, 70.5% between 2 and 6years, and 100% after 7years). Oxygen duration was linked to a biopsy-proven diagnosis (p = 0.02) and to the use of a nutritional support (p = 0.003). Corticosteroids were largely prescribed at diagnosis, with no evident respiratory or nutritional effect during follow-up. Among 23 patients with an initial failure to thrive, 12 (52.2%) had no weight recovery. Initial enteral feeding (17/54, 31.5%) was stopped at a mean age of 43months (3 to 120), with no effect on cure and oxygen liberation at the last visit. Conclusion: Our results show that NEHI has a globally positive, but unequal, improvement over time. Further prospective studies are needed to better clarify the different trajectories of patients with NEHI. What is Known: • Neuroendocrine cell hyperplasia of infancy (NEHI) is an interstitial lung disease whose long-term outcome is considered positive from very few studies including heterogeneous populations. What is New: • The 68-month follow-up of our 54-patient cohort showed respiratory/nutritional symptom persistence in 72.2%, oxygen requiring in 34%, and asthma in 37%. When controlled, radiological or functional improvement was noted in 56.8 and 40.7%. Further prospective studies are needed to better clarify the different trajectories of patients with NEHI.

Decision Making Surrounding Mode of Initial Enteral Feeding in Critically Ill Pediatric Patients

Wide practice variation and weak guidelines exist when considering enteral feeding options and the decision to proceed with gastric or postpyloric enteral feeding in critically ill infants and children. The purpose of this pilot study is to explore provider decision making in early feeding of critically ill pediatric patients, review the indications for choice of enteral feeding access, and qualitatively explore the role of institutional culture in medical decision making.

Enteral Feeding and Necrotizing Enterocolitis: Does Time of First Feeds and Rate of Advancement Matter?

The aim of the study was to determine if time to initial enteral feeding (EF) and rate of advancement are associated with necrotizing enterocolitis (NEC) or death. Secondary analysis of prospectively collected data of very-low-birth-weight infants (VLBWI: 400--1500 g) born in 26 NEOCOSUR centers between 2000 and 2014. Among 12,387 VLBWI, 83.7% survived without NEC, 6.6% developed NEC and survived, and 9.6% had NEC and died or died without NEC (NEC/death). After risk adjustment, time to initial EF (median = 2 days) was not associated with NEC; however, delaying it was protective for NEC/death (odds ratio [OR] = 0.96; 95% confidence interval [CI] 0.93--0.99). A slower feeding advancement rate (FAR) was protective for NEC (OR = 0.97; 95% CI = 0.94-0.98) and for NEC/death (OR = 0.98; 95% CI = 0.96-0.99). In VLBWI, there was no association between an early initial EF and NEC, although delaying it was associated with less NEC/death. A slower FAR was associated with lower risk of both outcomes.

Guidelines for gastrostomy tube placement and enteral nutrition in patients with severe, refractory hypoglycemia after gastric bypass.

Postbariatric hypoglycemia (PBH) affects up to 38% of Roux-en-Y gastric bypass (RYGB) patients. Severe cases are refractory to diet and medications. Surgical treatments including bypass reversal and pancreatectomy are highly morbid and hypoglycemia often recurs. We have developed a highly effective method of treatment by which enteral nutrition administered through a gastrostomy (G) tube placed in the remnant stomach replaces oral diet: if done correctly this reverses hyperinsulinemia and hypoglycemia, yielding substantial health and quality of life benefits for severely affected patients. To provide clinical guidelines for placement of a G-tube to treat postRYGB hypoglycemia, including candidate selection, preoperative evaluation, surgical considerations, and post-RYGB management. Stanford University Hospital and Clinics. Based on our relatively large experience with placing and managing G-tubes for PBH treatment, an interdisciplinary task force developed guidelines for practitioners. A team approach (endocrinologist, dietitian, surgeon, psychologist) is recommended. Appropriate candidates have a history of RYGB, severe hypoglycemia refractory to medical-nutrition therapy, and significantly affected quality of life. Preoperative requirements include education and expectation setting, determination of initial enteral feeding program, and establishing service with a home enteral provider. Close postoperative follow-up is needed to ensure success and may require adjustments in formula and mode/rate of delivery to optimize tolerance and meet nutritional goals. G-tube nutrition must fully replace oral nutrition to prevent hypoglycemia. G-tube placement in the remnant stomach represents a relatively well-tolerated and effective treatment for severe, refractory hypoglycemia after RYGB.

The Role of Dietitian in Improving Energy and Protein Intake in Traumatic Brain Injury Patients Admitted to the Neurosurgical Intensive Care Unit

Introduction:Early and sufficient nutritional support is vital to improve outcomes in patients with traumatic brain injury. This study aims to determine the effects of dietitian involvementin the nutritional and clinical outcomes inpatients with traumatic brain injuries admitted tothe neurosurgical ICU. Materials &amp;Methods: Forty-eight male patients with traumatic brain injuries admitted to Poursina Hospital neurosurgical ICU were studied, retrospectively. Patients were divided to either receive dietitian intervention or without any nutritional recommendation(control). Demographic information, Glasgow Coma Scale and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, the timing of initial enteral feeding, the amount of energy and protein intakeon day 4, the duration of mechanical ventilation and ICU length of stay were recorded. Results:Patients under the dietitian recommendation had significantly lower timing of initial enteral nutrition compared to the other cases (P=0.02). The average energy or protein intake and the percentage of target energy or protein intake on day4 appeared to be significantly lower in the subjects in the control group than in those with nutritional intervention(P≤0.001). There was no statistically significant difference in the duration of mechanical ventilation and ICU length of staybetween different groups of patients. Conclusions:Instead of occasional consultations for exclusive cases, the daily attendance of dietitians during multidisciplinary rounds of ICU is required to assess the nutritional needs of patients.

Optimizing early enteral nutrition in severe stroke (OPENS): protocol for a multicentre randomized controlled trial

BackgroundMalnutrition is one of the crucial factors associated with poor prognosis in critical ill patients, yet a significant evidence gap surrounds the management of initial enteral feeding in severe stroke. The Optimizing Early Enteral Nutrition in Severe Stroke (OPENS) trial will compare a strategy of modified full enteral nutrition (EN) (standard full EN in conjunction with prokinetic drug) and a strategy of permissive underfeeding (40 to 60% of estimated caloric requirements) with standard full EN (advancement to target nutrition goals) in patients with severe stroke.MethodsThe OPENS trial is a multicenter randomized controlled study. A total of 600 adult patients with severe stroke will be enrolled in 12 study sites in China, and randomized to standard full EN, modified full EN, or permissive underfeeding. The primary outcome measurement is the proportion of participants with a poor outcome (modified Rankin Scale ≥3) at day 90 of enrollment. Secondary outcomes include incidence rates of complications during hospitalization, disability at hospital discharge, and the ability of activities of daily living at day 90 of enrollment. The relationship between intervention and the primary outcome will be analyzed using multivariate logistic regression adjusted for study site, demographics, and baseline characteristics.DiscussionThe OPENS trial will explore the optimum initial feeding strategy for acute severe stroke. This trial is, therefore, an important step in bridging the evidence gap surrounding the enteral feeding for patients with severe stroke during the first week of hospitalization.Trial registrationClinicalTrials.gov Identifier: NCT02982668; First Posted: December 5, 2016.

Incidence and Management of Chylous Ascites and Chylothorax Following Intestine and Multivisceral Transplant

Introduction: There have been no published reports looking at the incidence of chyle leaks (chylous ascites or chylothorax) in adult patients following Intestinal or Multivisceral transplant. Use of a Medium Chain Triglyceride (MCT) enriched feed is proposed to prevent the development of chlye leaks following non-transplant abdominal or thoracic surgery. We reviewed the incidence of chyle leak in the post-operative period in a cohort of patients transplanted at Addenbrooke’s Hospital, Cambridge, UK. Methods: A retrospective search of patient notes, radiology reports and biochemical analysis of post operative fluid collections was carried out on all patients who underwent Intestinal and Multivisceral Transplant between January 2006 and September 2016. Chylous fluid was defined by the physical appearance of fluid and in some case by measured triglycerides (110mg/dL). Results: During this period a total of 71 transplants were performed on 65 patients. 17 transplants (24%) developed either chylous ascites or chylothorax following transplant. Three of these patients developed both chylous ascites and chylothorax, while 3 patients developed only a chylothorax and 11 developed only chylous ascites. Ten patients had chylous fluid confirmed biochemically. The mean length of time to diagnosis of Chylous fluid post transplantation was 30 days, with a range of 4 to 63 days. Initial enteral feeding was with a MCT-rich lipid source in 2/3 of patients, or a completely fat-free feed in 1/3. Despite this, rates of development of chyle leaks were relatively high in both groups (23% and 22% respectively). Conclusion: The development of chylous ascites is related to the disruption of the lymphatic system at the time of surgery. [1]After transplant, patients receive parenteral nutrition until the transplanted graft begins to function. After this oral intake is permitted and feeding commences via a jejunostomy, if one has been placed during surgery. MCTs are not absorbed by the lymphatics therefore use of a MCT-rich enteral feed has been successful in other scenarios. However, a significant number of our patients developed chlye leaks despite this approach. A change in practice to a fully fat-free feed did not reduce the incidence, but patients were also allowed to eat during this time, which may account for these findings. Reference: 1. Cardenas A, Chorpa S. Chylous ascites. American Journal of Gastroenterology 2002;97:1896–900.

Early enteral feeding following repair of gastroschisis is associated with shorter length of admission and better nutritional outcomes

Aim: The aim of the study was to review timing and substrate of initial enteral feeding in the management of infants with gastroschisis (GS) with analysis of their relationship to nutritional outcomes and length of Neonatal Intensive Care Unit (NICU) admission. Methods: A retrospective review was conducted of consecutive admissions of infants with GS to a quaternary NICU between 2010 and 2016. Demographic, clinical data and data on nutritional status and growth were collected. Relationships between time to initiate enteral feeding and length of NICU admission, duration of parenteral nutrition (PN), and time taken to regain birth weight were assessed, as well as effect of exclusive human milk on length of NICU admission and duration of PN. Results and Conclusions: Survival in this cohort was 100%. Significant positive correlations were found between time taken to initiate enteral feeding after abdominal closure and each of the primary outcomes: length of NICU stay, duration of PN, and time taken to regain birth weight. There was no effect of exclusive human milk feeding on either duration of PN or length of NICU stay. A higher rate of exclusive human milk feeding was observed than in published literature.

Association between illness severity and timing of initial enteral feeding in critically ill patients: a retrospective observational study

BackgroundEarly enteral nutrition is recommended in cases of critical illness. It is unclear whether this recommendation is of most benefit to extremely ill patients. We aim to determine the association between illness severity and commencement of enteral feeding.MethodsOne hundred and eight critically ill patients were grouped as “less severe” and “more severe” for this cross-sectional, retrospective observational study. The cut off value was based on Acute Physiology and Chronic Health Evaluation II score 20. Patients who received enteral feeding within 48 h of medical intensive care unit (ICU) admission were considered early feeding cases otherwise they were assessed as late feeding cases. Feeding complications (gastric retention/vomiting/diarrhea/gastrointestinal bleeding), length of ICU stay, length of hospital stay, ventilator-associated pneumonia, hospital mortality, nutritional intake, serum albumin, serum prealbumin, nitrogen balance (NB), and 24-h urinary urea nitrogen data were collected over 21 days.ResultsThere were no differences in measured outcomes between early and late feedings for less severely ill patients. Among more severely ill patients, however, the early feeding group showed improved serum albumin (p = 0.036) and prealbumin (p = 0.014) but worsened NB (p = 0.01), more feeding complications (p = 0.005), and prolonged ICU stays (p = 0.005) compared to their late feeding counterparts.ConclusionsThere is a significant association between severity of illness and timing of enteral feeding initiation. In more severe illness, early feeding was associated with improved nutritional outcomes, while late feeding was associated with reduced feeding complications and length of ICU stay. However, the feeding complications of more severely ill early feeders can be handled without significantly affecting nutritional intake and there is no eventual difference in length of hospital stay or mortality between groups. Consequently, early feeding shows to be a more beneficial nutritional intervention option than late feeding in patients with more severe illness.

The Influence of Neocate in Paediatric Short Bowel Syndrome on PN Weaning

Clinical management of short bowel syndrome remains a multistage process. Although PN is crucial, early introduction of enteral feeding is mandatory. We describe retrospectively 4 patients with an ultrashort bowel who could be weaned off PN on very short terms after introduction of an amino-acid-based formula (Neocate). Patient 1 had congenital short bowel with 50 cm small bowel and 30 cm colon. He had persistent diarrhoea on a semielementary formula. When Neocate was introduced he could be weaned from PN within 6 months. Patient 2 needed multiple surgical interventions because of NEC at D 27. He maintained 40 cm small bowel and an intact colon and remained PN dependent on semielemental formula. After introducing Neocate, PN could be weaned within 3 months. In the next 2 patients, Neocate was introduced as initial enteral feeding after bowel resection following antenatal midgut volvulus. Patient 3 had 20 cm small bowel and an intact colon. PN was weaned after 2 months. Patient 4 had 9 cm small bowel and an intact colon. PN was weaned after 13 months. In all patients Ileocaecal valve (ICV) was preserved. No consensus is reached on the type of formula to use for short bowel syndrome. Compared to recent data in the literature, the weaning period in these 4 patients was significantly shortened on an aminoacid based formula. The reason for this may lie in the antiallergic properties of this formula. We recommend the use of an amino-acid-based formula to induce earlier weaning of PN.

Nutritional Response of Patients in an Intensive Care Unit to an Elemental Formula vs A Standard enteral Formula

Elemental diets are traditionally used for nutrition support in patients with diseases that affect absorption and digestion. An elemental diet has been recommended for initial enteral feeding during parenteral nutrition (1). Clinical trials have shown that hydrolyzed protein formulas are as effective as amino acid formulas in inducing remission of Crohn's disease (2,3). In clinical practice, however, personal bias continues to exist when enteral formulas are chosen. An elemental diet potentially benefits patients with hypoalbuminemia, which may compromise absorption and result in diarrhea. A previous study comparing an elemental formula with a standard enteral formula in critically ill patients with hypoalbuminemia indicated no difference in diarrhea and nutritional markers between groups (4). However, patients were allowed an oral diet ad libitum, the elemental formula was peptide based, and both study formulas contained moderate amounts of fat. A similar study of postoperative jejunostomy feedings in which a low-fat, amino-acid-based elemental formula was used confirmed these observations (some patients in the study consumed an oral diet) (5). The results of these trials could have been affected by the allowance of oral feedings.

Survey: Methods of Feeding Low-Birth-Weight Infants

The directors of 269 neonatal intensive care units were surveyed to determine how low-birth-weight infants are being fed. Feeding practices were based on birth weight, with the smallest infants receiving parenteral nutrition for the longest time after birth. First enteral feedings usually were given by the nasogastric route in infants with birth weight of 1,500 g or less, but transpyloric feedings were used in 15% of neonatal intensive care units for infants with birth weight less than 1,000 g. The initial enteral feeding was sterile water in 56% to 58% of the neonatal intensive care units, but was glucose water or milk in the others. Once enteral feeding was established, both human milk from the infant's own mother and commercial formula were used. Whether human milk was mixed or alternated with infant formula, or whether some infants in the nursery were fed human milk while others were fed formula, was not determined. The type of infant formula fed to low-birth-weight infants depended on the infant's birth weight and clinical status. Both human milk and formula were supplemented with energy (fat or carbohydrates) and vitamins, but not with calcium and phosphorus, in most neonatal intensive care units. Some vitamins, such as vitamins A and D, may be oversupplemented, while others, such as folic acid, may be undersupplemented.