Standardized Feeding Protocol Research Articles

Proactive Use of a Human Milk Fat Modular in the Neonatal Intensive Care Unit: A Standardized Feeding Protocol.

Our revised feeding protocol, established in October 2021, called for a human milk fat modular (Prolact CR) to be added to all infant feeding when parenteral nutrition (PN) and lipids were discontinued. The human milk fat modular concentration is 4 mL per 100 mL feed, providing approximately an additional 2 kcal/oz. We tracked data to compare (1) the use of the human milk fat modular, (2) the use of the human milk +8 fortifier, (3) overall growth before and after feeding protocol changes, and (4) cost differences between protocols. Thirty-six VLBW infants were followed prospectively upon the introduction of the revised feeding protocol. In the revised era, the need for human milk +8 fortifier decreased from 43% to 14%. The decrease in the cost of a more costly fortifier provided a cost savings of USD 2967.78 on average per infant. Overall growth improved from birth to discharge, with severe malnutrition declining from 3.3% to 2.7% and moderate malnutrition declining from 37% to 8%. With the proactive use of a human milk fat modular in a standardized feeding protocol, our VLBW infants showed improved growth, lower malnutrition rates, and decreased use of higher caloric fortifiers.

Zebrafish Feed Intake: A Systematic Review for Standardizing Feeding Management in Laboratory Conditions.

Zebrafish are one of the most used animal models in biological research and a cost-effective alternative to rodents. Despite this, nutritional requirements and standardized feeding protocols have not yet been established for this species. This is important to avoid nutritional effects on experimental outcomes, and especially when zebrafish models are used in preclinical studies, as many diseases have nutritional confounding factors. A key aspect of zebrafish nutrition is related to feed intake, the amount of feed ingested by each fish daily. With the goal of standardizing feeding protocols among the zebrafish community, this paper systematically reviews the available data from 73 studies on zebrafish feed intake, feeding regimes (levels), and diet composition. Great variability was observed regarding diet composition, especially regarding crude protein (mean 44.98 ± 9.87%) and lipid content (9.91 ± 5.40%). Interestingly, the gross energy levels of the zebrafish diets were similar across the reviewed studies (20.39 ± 2.10 kilojoules/g of feed). In most of the reviewed papers, fish received a predetermined quantity of feed (feed supplied). The authors fed the fish according to the voluntary intake and then calculated feed intake (FI) in only 17 papers. From a quantitative point of view, FI was higher than when a fixed quantity (pre-defined) of feed was supplied. Also, the literature showed that many biotic and abiotic factors may affect zebrafish FI. Finally, based on the FI data gathered from the literature, a new feeding protocol is proposed. In summary, a daily feeding rate of 9-10% of body weight is proposed for larvae, whereas these values are equal to 6-8% for juveniles and 5% for adults when a dry feed with a proper protein and energy content is used.

Complications and Outcomes of Nutritional Guidelines Implementation in Low Birth Weight Infants

Background: Necrotizing enterocolitis (NEC) is one of the most disastrous complications of premature infants. Using preterm feeding protocols can decrease NEC risk and improve feeding intolerance. Objective: To compare the rate of NEC and other comorbidities between low-birth-weight (LBW) infants that received a Bhumibol Adulyadej Hospital (BAH) standardized feeding protocol and those that underwent previous nutritional practice. Materials and Methods: A quasi-experimental study was conducted at neonatal intensive care unit (NICU) in BAH, Thailand. Participants were LBW newborns delivered at BAH between December 1, 2018 and March 31, 2020. The subjects were divided into the control group who underwent previous nutritional practice and the study group who were implemented with a new nutritional guideline. Primary outcome was NEC rate. Secondary outcomes were preterm complications such as neonatal sepsis, catheter-related bloodstream infection, parenteral nutrition-associated liver disease, osteopenia of prematurity, and intraventricular hemorrhage. Feeding achievement outcomes and growth outcome parameters were also evaluated. Results: Data were analyzed on 71 infants in the control group and 68 infants in the study group. The rate of NEC was not different between the two groups with 7% in the control versus 5.9% in the study (p=1.000). In addition, other preterm complications were not different between groups. However, the time to reaching full enteral feeding was shorter in the study group at 14 in the control versus 10 in the study (p<0.001). Day of life when the fortification start was significantly earlier in the study group at 15.5 in the control versus 12 in the study (p=0.008). Other feeding achievement outcomes also improved, which was evidenced by fewer parenteral nutrition (PN) days at 11.55 in the control versus 7.0 in the study (p=0.004) and shorter duration of indwelling central line at 9.5 in the control versus 7 in the study (p=0.001). Conclusion: Initiation of the new nutritional guideline produced a lower rate of NEC as compared to previous practice. Furthermore, the time to full enteral feeding, PN days, and central line days were decreased without increasing other preterm complications. Keywords: Low birth weight; Nutrition; Complication; NEC

Nutritional Strategies to Optimize Outcomes among Infants with Congenital Heart Disease.

Growth failure is common among infants with congenital heart disease (CHD), affecting approximately half of all infants with CHD. Achieving good growth is difficult secondary to both cardiac and noncardiac factors that affect energy expenditure and nutritional intake. Growth failure is associated with poor outcomes, including mortality, prolonged length of hospital stay, delayed cardiac surgery, postoperative complications, and neurodevelopmental delay. Clinical practice varies widely when it comes to how nutrition is managed in these infants, with varying approaches to enteral feeding initiation, advancement, and discontinuation. This variation persists despite several practice guidelines that have been created in recent years to guide nutritional care. Standardized feeding protocols have been proven to reduce growth failure and improve outcomes for this patient population. Centers and clinicians should be encouraged to adopt existing guidelines, or create their own from evidence-based literature, to improve growth and outcomes for infants with CHD.

A standardized feeding protocol ensured recommended nutrient intakes and prevented growth faltering in preterm infants < 29 weeks gestation.

Nutrition is a cornerstone of postnatal care to prevent compromised growth and support short- and long-term health outcomes in preterm infants. We aimed to evaluate nutritional intakes and growth among infants <29 weeks gestation after implementation of a standardized feeding protocol. This is an observational cohort secondary analysis of data from the ImNuT study (Immature, Nutrition Therapy, NCT03555019). To reduce variations in nutritional practice and ensure accommodation to current guidelines, we developed a standardized feeding protocol. Detailed information on actual nutritional intakes, growth and biochemistry was prospectively collected and assessed from birth to 36 weeks postmenstrual age (PMA). Median (range) gestational age and birth weight were 26+6 (22+6-28+6) weeks and 798 (444-1485) g. Energy and macronutrient intakes progressively increased from birth through transition to exclusive enteral feeds. Parenteral nutrition was weaned at median (IQR) day 11 (9, 14) when nutritional requirements were met by exclusively enteral feeds. Infants exhibited a median (IQR) weight loss of 7.8% (5.7, 11.6) and regained birth weight by day 8 (7, 11). Average velocity in weight, length and head circumference from birth to 36 weeks PMA were in accordance with target growth rates; median (IQR) 15.8 (14.7, 17.7) g/kg/d, 1.1 (0.98, 1.3) cm/week and 0.82 (0.83, 0.89) cm/week. At 36 weeks PMA, only 3% of infants exhibited moderate growth faltering (decline in weigh-for-age z score >1.2 from birth), and none severe. In infants <29 weeks gestation, the standardized feeding protocol was well tolerated. Nutrient intakes and growth were close to recommendations.

Dilemmas in feeding infants with intestinal failure: a neonatologist's perspective.

Intestinal failure in neonatal and pediatric populations can be debilitating for patients and difficult to manage for clinicians. Management strategies include referral to an intestinal rehabilitation center, small volume trophic feeds to stimulate the intestine with cautious advancement of enteral nutrition using a standardized and evidence-based feeding protocol, and supplemental parenteral nutrition to optimize an infant's growth and nutrition. In this review, we discuss the causes of intestinal failure, parenteral nutrition strategies, enteral feeding initiation and advancement protocols, as well as the challenges in feeding an infant with intestinal failure.

Prophylactic Use of Prolact CR in NICU standardized Feeding Protocol

Upon completion, participant will be able to describe supportive evidence for prophylactic use of Prolact CR in a standardized feeding protocol for very low birthweight infants rather than use reactively.

Benefits of a Standardized Enteral Feeding Protocol on the Nutrition and Health Outcomes of Very Low Birth Weight Preterm Infants.

Purpose: To compare nutrition and health outcomes before and after implementing a standardized enteral feeding protocol on nutrition and health outcomes in very low birth weight preterm infants.Methods: A retrospective chart review was performed evaluating preterm infants, born less than 34weeks gestation and weighing less than 1500g, before and after the implementation of a standardized enteral feeding protocol. Outcomes included weaning of parenteral nutrition, initiation and advancement of enteral feeds, initiation of human-milk fortifier (HMF), change in weight z-score and neonatal morbidities.Results: Fifty-six infants (30 in pre-group, 26 in post-group) met the inclusion criteria. Infants in the standardized enteral feeding protocol group started enteral feeds earlier (p=0.039) and received full HMF fortification at lower weights (p=0.033) than those in the pre-group. Fewer days on continuous positive airway pressure (p=0.021) and lower rates of bronchopulmonary dysplasia (p=0.018) were also observed in the post-group. Weaning of parenteral nutrition and weight z-score were not significantly different between groups. There were no differences in other morbidities.Conclusion: Study results suggest that adopting a standardized enteral feeding protocol may promote early initiation of enteral feeds and fortification.

A Quality Improvement Project to Reduce Time to Full Enteral Feeds for Very Low Birth Weight Neonates

Adherence to standardized feeding guidelines has been proposed as a strategy to limit morbidity in very low birth weight neonates. Fostering adherence limits the variability in medicine that affects the quality of patient care. The aim of this study was to reduce by 20% the time to full enteral feeds in very low birth weight neonates in the NICU within a 12-month period. In a level IV regional perinatal center with low utilization of its feeding protocol, a 12-month quality improvement project was conducted with a key intervention of a feeding schedule calculator based on the unit standardized feeding protocol. Through studied education and implementation cycles, these feeding schedules were used to reduce time to full enteral feeds while monitoring adverse events related to their use. During the course of this quality improvement project, our time to full enteral feeds of 160 ml/kg/day of feeds reduced from 24.7 days to 17.7 days after process changes with special-cause variation noted on control charts. We also showed a significant reduction in mean central line duration over the course of the project from a baseline of 19 days to 14.5 days. Through a key intervention of a feeding volume calculator, we were able to reduce the time to full enteral feeds in neonates without any increase in adverse events of necrotizing enterocolitis or poor weight gain.

Preoperative Feeding in Single Ventricle Neonates is Predictive of Shorter Time to Goal Feed

Background: Patients with single ventricle anatomy are at increased risk of growth failure and malnutrition. Amongst cardiac centers, there is little standardization of feeding practices in this complex population. We hypothesized that initiation of our center’s preoperative feeding protocol would result in decreased gastrostomy tube (G-tube) use, decreased length of stay and would not result in increased Necrotizing Enterocolitis (NEC) rates. Methods: A single institution review of 52 patients who had undergone stage I single ventricle palliative repair was performed. Patient diagnoses were hypoplastic left heart syndrome (39%), atrioventricular canal (15%), and other (46%). Postoperative parameters such as time to goal feed and need for gastrostomy tube (G-tube) were compared among preoperatively fed and non-preoperatively fed groups. Time to goal feed was calculated as time from first postoperative enteral feed to goal volume of 100 mL/kg. Results: Of the 26 patients who met inclusion criteria for preoperative feeding, 22 patients (85%) were fed prior to surgery. Cox proportional hazard ratio revealed that age at surgery (p = 0.047) and being preoperatively fed (p = 0.001) were associated with reaching goal feed sooner. Multivariable analysis revealed that being preoperatively fed made a patient twice as likely to reach goal feed sooner (p = 0.047). Univariable logistic regression revealed that days on total parenteral nutrition (p = 0.018), length of hospitalization (p = 0.008), and time to 1st postoperative feed (p = 0.020) were significantly associated with higher odds of needing a G-tube postoperatively. Multivariable logistic regression did not show any predictors of postoperative G-tube usage. However, there was a trend towards lower G-tube usage in the preoperatively fed group. Conclusions: Implementing a standardized preoperative feeding protocol in single ventricle neonates can result in significantly shorter time to goal feed in preoperatively fed patients. It is beneficial for institutions to begin implementing standard feeding protocols to improve nutrition and growth outcomes.

60 Impact of sequential implementation of a standardized feeding protocol and donor breastmilk on necrotizing enterocolitis among preterm infants born &amp;lt;31 weeks gestation

Abstract Primary Subject area Neonatal-Perinatal Medicine Background Necrotizing enterocolitis (NEC) is the leading cause of gastrointestinal morbidity and mortality among preterm infants born &amp;lt;31 weeks. Nutritional interventions such as a standardized feeding protocol (SFP) and donor breastmilk (DBM) are recommended to reduce NEC. Objectives Our objective was to assess the impact of implementing a feeding protocol and pasteurized donor breastmilk protocol on NEC among preterm infants born &amp;lt; 31 weeks GA. Design/Methods Retrospective cohort study including 682 infants born &amp;lt; 31 weeks, who survived ≥ 14 days and were admitted to two tertiary NICUs from 2009-2018. Data was obtained from the local Canadian Neonatal Network database. Infants were classified into epochs, based on the timing of interventions: Epoch 1, baseline (2009-2012); Epoch 2, SFP (2013-2015); Epoch 3, SFP + DBM (2016-2018). The primary outcome was NEC stage ≥ 2. Multivariable logistic regression models were used to assess associations between epochs and outcomes and were adjusted for confounders. Results Among 682 infants, 46 (7%) had NEC and 74 (11%) had mortality/NEC. Rates of NEC decreased with each epoch: 10% (25/246) Epoch 1 (baseline); 5% (8/163) Epoch 2 (SFP); and 5% (13/273) Epoch 3 (SFP+DBM), (p&amp;lt;0.01) (Table1). SFP alone was associated with significantly lower odds of NEC compared to baseline (Epoch 2 vs 1, AOR 0.42, 95% CI 0.17-0.93) (Table 2). Implementation of DBM was not associated with lower odds of NEC compared to SFP alone (Epoch 3 vs 2, AOR 0.94, 95% CI 0.38-2.42) (Table2). Number of NPO days prior to the initiation of enteric feeds after birth decreased in Epoch 3 (Epoch 1&amp;2: 2 days versus Epoch 3: 1 day; p&amp;lt;0.01). Exclusive human breastmilk feeds during the first 3 weeks increased from 62% in Epoch 2 to 82% in Epoch 3 (p&amp;lt;0.01). A significant decrease in number of total parenteral nutrition and central venous line (CVL) days was observed from Epoch 1 to 3 (25 to 15 days and 26 to 15 days respectively; p&amp;lt;0.01) (Table 1), this was reflected in the decrease in late onset sepsis (Epoch 3 vs 1, AOR 0.55, 95% CI 0.35-0.86). Conclusion Implementation of SFP was associated with a significant decrease in NEC among infants born &amp;lt; 31 weeks. Combining the SFP and DBM did not further decrease NEC, but was associated with shorter NPO days, higher exclusive human breastmilk exposure, and significant decrease in number of central venous line (CVL) days.

A Call to Action to Fight for Equity and End Necrotizing Enterocolitis Disparities.

A Call to Action to Fight for Equity and End Necrotizing Enterocolitis Disparities.

Standardized Feeding Protocol Improves Delivery and Acceptance of Enteral Nutrition in Children Immediately After Liver Transplantation.

Delivery of adequate nutrition after liver transplantation (LT) surgery is an important goal of postoperative care. Existing guidelines recommend early enteral nutrition after abdominal surgery and in the child who is critically ill but data on nutritional interventions after LT in children are sparse. We evaluated the impact of a standardized postoperative feeding protocol on enteral nutrition delivery in children after LT. Data from 49 children (ages 0-18years) who received a LT prior to feeding protocol implementation were compared with data for 32 children undergoing LT after protocol implementation. The 2 groups did not differ with respect to baseline demographic data. After protocol implementation, enteral nutrition was started earlier (2 versus 3days after transplant; P=0.005) and advanced faster when a feeding tube was used (4 versus 8days; P=0.03). Protocol implementation was also associated with reduced parenteral nutrition use rates (47% versus 75%; P=0.01). No adverse events occurred after protocol implementation. Hospital length of stay and readmission rates were not different between the 2 groups. In conclusion, implementation of a postoperative nutrition protocol in children after LT led to optimized nutrient delivery and reduced variability of care.

Impact of a Care Bundle on the Incidence of Necrotizing Enterocolitis in the Neonatal Intensive Care Unit

Objective: Evaluate the impact of a care bundle on the incidence of necrotizing enterocolitis (NEC) in the neonatal intensive care unit. Study Design: Retrospective, single-center, population comparison of patients diagnosed with NEC before and after implementing an NEC care bundle utilizing standardized feeding protocol, donor milk program, transfusion protocol, early antibiotic protocol, and restricted indomethacin use. Result: Incidence of NEC fell from 1.92 to 0.83% (P &lt;0.0001). Incidence of NEC in the 23-27 weeks gestation group decreased from 14.21 to 6.09% (P = 0.0009). In the 28-30 weeks gestation group, NEC incidence decreased from 5.56 to 2.10% (P = 0.0096). Significant reduction of recurrent NEC and transfusion-associated NEC was observed. Conclusion: Implementation of an NEC care bundle reduced NEC incidence, with the greatest impact seen in the most vulnerable preterm and very preterm infants.

Enteral Nutrition in Term Infants with Congenital Heart Disease: Knowledge Gaps and Future Directions to Improve Clinical Practice.

Optimal nutrition is essential to improve short- and long-term outcomes in newborns with congenital heart disease (CHD). Nevertheless, several issues on nutritional management and concerns about the potential risk of complications related to enteral feeding exist. This narrative review aims to summarize and discuss the available literature on enteral feeding in term infants with CHD. A wide variability in feeding management exists worldwide. Emerging approaches to improve nutritional status and outcomes in infants with CHD include: implementation of a standardized enteral feeding protocol, both preoperative and postoperative, clearly defining time of initiation and advancement of enteral feeds, reasons to withhold, and definitions of feeding intolerance; early minimal enteral feeding; enteral feeding in stable term infants on hemodynamic support; evaluation of enteral feeding in term infants with umbilical arterial catheters and during prostaglandin infusion; assessment and support of oro-motor skills; and promotion and support of breastfeeding and provision of mother’s own milk or donor milk when mother’s own milk is not available. As evidence from term infants is scarce, available observations and recommendations partially rely on studies in preterm infants. Thus, well-designed studies assessing standardized clinically relevant outcomes are needed to provide robust evidence and shared recommendations and practices.

A preoperative standardized feeding protocol improves human milk use in infants with complex congenital heart disease.

To evaluate the hypothesis that implementation of a preoperative standardized feeding protocol increases human milk use in infants with complex congenital heart disease (CHD). Single-center, quasi-experimental study of infants with complex CHD. A cohort of 546 infants pre protocol was compared to 55 patients post protocol. Feeding regimen and peri-operative outcomes information were collected. Human milk use increased significantly (58.4% versus 100%, p < 0.01) and there was no formula use post protocol (18.7% versus 0%, p < 0.01). Preoperative necrotizing enterocolitis occurred in 18/546 (3.3%) infants pre protocol versus 1/55 (1.8%) post protocol, p = 1.00. Days to full feeds and length of hospital stay in both cohorts were not significantly different. Successful implementation of a preoperative standardized feeding protocol can increase human milk and decrease formula use in infants with complex CHD without significant adverse outcomes. A larger study is needed to evaluate the association of human milk use with peri-operative outcomes.

The Effect of a Continuous Milk Warming System on Weight Gain in Very Low Birth-Weight Infants: A Randomized Controlled Trial.

Few studies support the practice of warming human milk before feeding. No studies have compared the method of warming milk and its effect on growth, particularly in preterm infants. To evaluate growth in preterm infants receiving continuously warmed human milk as compared with infants receiving human milk warmed in a hot water bath before feeding. Forty-four infants less than 32 weeks' gestation admitted to a regional referral level IV neonatal intensive care unit in south central United States were randomly assigned to either the experimental group (continuous warming: n = 22) or the control group (hot water bath: n =22) for 10 days. All infants were on full human milk feedings (120-130 kcal/kg/d) as part of a standardized feeding protocol. Tolerance and weight gain over the 10-day period were used to evaluate the effectiveness of continuous milk warming. There was a significant difference in weight gain for infants receiving continuously warmed milk compared with infants receiving standard warmed milk (203.73 ± 70.71 vs 271.95 ± 67.40, P = .002). The use of continuous milk warming improves weight gain in very low birth-weight infants.

Evidence-Based Practices Reduce Necrotizing Enterocolitis and Improve Nutrition Outcomes in Very Low-Birth-Weight Infants.

Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency in preterm infants. Survivors may suffer both short- and long-term morbidities. Current evidence suggests that the incidence of NEC can be reduced by standardizing the care delivery in addressing key risk factors including an altered gut microbiome, use of formula milk, hyperosmolar feeds, and unrestricted use of high-risk medications METHODS: Since 2014, the department has a workgroup who analyzed all cases of NEC within a month of diagnosis to identify preventable risk factors. Existing evidence-based quality improvement strategies were revised and new ones were implemented sequentially over the next 4 years. These strategies include (1) a standardized feeding protocol, (2) early initiation of enteral feeding using human milk, (3) optimization of the osmolality of preterm milk feeds using standardized dilution guidelines for additives, and (4) promotion of healthy microbiome by use of probiotics, early oral care with colostrum and by restricting high-risk medications and prolonged use of empirical antibiotics RESULTS: Baseline characteristics of the patients including sex, gestational age, and birth weight were similar during the study period. After implementing the evidence-based practices successively over 4 years, the incidence of NEC in very- low birth-weight (VLBW) infants dropped from 7% in 2014 to 0% (P < .001) in 2018. The duration of parenteral nutrition, use of central line, and days to full feeds were also reduced significantly (P < .05) CONCLUSION: Adopting evidence-based best practices resulted in a significant decrease in the incidence of NEC and improved the nutrition outcomes in VLBW infants.

Effects of standardized feeding protocol on growth velocity and necrotizing enterocolitis in extremely low birth weight infants

Objective To assess the effect of a standardized feeding protocol (SFP) on growth velocity (GV) and necrotizing enterocolitis (NEC) in extremely low birth weight infants. Methods This single-study center retrospectively compared growth, nutritional, and gastrointestinal outcomes in two infant cohorts before (cohort 1; n = 145) and after (cohort 2; n = 69) SFP implementation. Results Although weekly GV in the first 4 weeks of life did not differ between the two cohorts, median GV at 36 weeks' post-menstrual age (PMA) was higher in cohort 2 compared with cohort 1 (26.8 g/day [24.7, 28.9] vs 24.9 g/day [22.9, 28.3], p = 0.02). The odds of NEC were lower in cohort 2 by 63% after adjusting for birth weight, small-for-gestational-age, and gender (OR = 0.38, 95% CI 0.142-0.993, p = 0.047). Conclusion Our SFP was associated with improved GV at 36 weeks' PMA and a lower adjusted rate of NEC.

High Flow Oxygen Therapy and the Pressure to Feed Infants With Acute Respiratory Illness

PurposeInfants hospitalized for an acute respiratory illness often require the use of noninvasive respiratory support during the initial stage to improve their breathing. High flow oxygen therapy (HFOT) is becoming a more popular means of noninvasive respiratory support, often used to treat respiratory syncytial virus/bronchiolitis. These infants present with tachypnea and coughing, resulting in difficulties in coordinating sucking and swallowing. However, they are often allowed to feed orally despite having high respiratory rate, increased work of breathing and on HFOT, placing them at risk for aspiration. Feeding therapists who work with these infants have raised concerns that HFOT creates an additional risk factor for swallowing dysfunction, especially with infants who have compromised airways or other comorbidities. There is emerging literature concluding changes in pharyngeal pressures with HFOT, as well as aspiration in preterm neonates who are on nasal continuous positive airway pressure. However, there is no existing research exploring the effect of HFOT on swallowing in infants with acute respiratory illness. This discussion will present findings from literature on HFOT, oral feeding in the acutely ill infant population, and present clinical practice guidelines for safe feeding during critical care admission for acute respiratory illness.ConclusionGuidelines for safety of oral feeds for infants with acute respiratory illness on HFOT do not exist. However, providers and parents continue to want to provide oral feeds despite clinical signs of respiratory distress and coughing. To address this challenge, we initiated a process change to use clinical bedside evaluation and a “cross-systems approach” to provide recommendations for safer oral feeds while on HFOT as the infant is recovering from illness. Use of standardized feeding evaluation and protocol have improved consistency of practice within our department. However, further research is still necessary to develop clinical practice guidelines for safe oral feeding for infants on HFOT.