Objectives and Study

Human milk (HM) is considered the ideal source of nutrition for all infants but often falls short in providing sufficient protein/non-protein calories in term infants with surgical conditions involving the heart or gastrointestinal tract. Currently, the only option for these infants is fortification with formula, which carries its own risk for deleterious outcomes such as necrotizing enterocolitis (NEC). Two separate clinical trials were conducted in infants with single ventricle physiology (SVP) and congenital gastrointestinal disorders (CGD) (gastroschisis, omphalocele and intestinal atresias).

Methods

Experimental groups were fed exclusive human milk (EHM) diets of mother’s own milk (MOM), pasteurized donor human milk (PDHM) fortified with a novel human milk-based fortifier (HMBF) (PBCLN-002) specifically formulated for the term infant. The control diet consisted of MOM, a cow’s milk fortifier and/or formula. The SVP study was a prospective, randomized, controlled trial of 107 infants, while the CGD trial was an open-label comparative effectiveness trial of 151 prospective infants with retrospective matching based on diagnosis, sex, birthweight (BW) and gestational age (GA). Growth was evaluated due to its critical importance in these critically ill babies, particularly in neurodevelopment.

Results

Baseline characteristics were well matched between the groups in both studies. The growth results are shown in Table 1.

Babies receiving PBCLN-002 grew significantly faster in terms of weight velocity and demonstrated comparable length and head circumference velocity. In addition, necrotizing enterocolitis (NEC) rates were reduced to 1.8% and 2.0% for the EHM group as compared to 3.6% and 7.3% in control groups for SVP and CGD respectively.

Conclusions

Neonates with the high-risk surgical conditions SVP or CGD fed HM fortified with PBCLN-002 demonstrated increased growth velocity by the time of discharge. Furthermore, they had a decrease in the incidence of overall NEC. The effect on weight gain and intestinal disease may translate into beneficial long-term effects on neurodevelopment.

Objectives and Study

Optimal nutrition is recognized to impact outcomes of critically ill patients. In 2017 the Society of Critical Care Medicine (SCCM) and the American Society of Parenteral and Enteral Nutrition (ASPEN) published guidelines for nutritional support of the critically ill pediatric patient. We aimed to analyze our current practices in light of these recommendations in order to identify obstacles to meeting nutritional needs in our unit.

Methods

We analyzed our practices by retrospective review. All children aged one month to sixteen years admitted in our unit from July 2017 to January 2020 were included. We focused on meeting two ASPEN recommendations: feeding at 48 hours after admission and meeting one third of nutritional needs after seven days. The following data were collected at the time of admission, at 48 hours and 7 days: ventilation, extracorporeal life support (ECSL), pressor support, and subjects were grouped according to underlying disease category. Ethical clearance was obtained without patient consent as this was a quality improvement study.

Results

Five hundred and thirty-three patients qualified for the study. After 48 hours of hospitalization, 402/533 (75.4%) of patients received early nutrition. The following factors were associated with not reaching nutritional goals at 48H: invasive ventilation support, inotrope support, and ECSL. Noninvasive ventilation support was not an obstacle to implementing ASPEN recommendations. After 7 days, 95/118 (80.5%) met their recommended caloric target. The main obstacle to meeting nutritional recommendations was invasive ventilation (p 0.059).

Conclusions

In a representative pediatric ICU, obstacles to meeting ASPEN nutritional recommendations included hemodynamic instability or invasive ventilator support, especially 48 hours from admission. After seven days, the only obstacle to meeting ASPEN recommendation was being under invasive ventilation support. As a quality improvement study, this retrospective review helped us to upgrade our nutritional management by focus our intervention in patient under invasive ventilation support.

Objectives and Study

To evaluate the impact of NCPAP vs HHHFNC on FI in preterm infants with RDS.

Methods

This was a multicentre randomized trial involving 13 neonatal intensive care units in Italy from November 2018 to June 2021. Preterm infants with a gestational age (GA) 25-29 weeks, suitable for enteral feeding, and stable on a non-invasive respiratory support for at least 48 h within the first 7 days of life were enrolled into the study. The intervention was the randomization to NCPAP or HHHFNC.Primary outcome was the time to full enteral feeding (FEF), defined as an enteral intake of 150 mL/Kg/day. Secondary outcomes were median daily enteral increment, signs of FI, effectiveness of the respiratory support assigned at randomization, SatO₂/FiO₂ at changes of respiratory support, and growth.

Results

Two-hundred forty-seven infants, median GA of 28 weeks (IQR, 27 to 29 weeks), were enrolled (122 NCPAP; 125 HHHFNC). The estimates of FEF probability showed no differences between the two arms (Figure 1). The median time to FEF was 14 days (95% CI, 11 to 15 days) in NCPAP and 14 days (95% CI, 12 to 18 days) in HHHFNC arm, similar results were observed in the subgroup of infants < 28 weeks GA. On the first change of respiratory support higher SatO₂/FiO₂ ratio (4.6; IQR, 4.1 to 4.7 vs 3.7; IQR, 3.2 to 4.0) and lower rate of ineffectiveness (4.8% vs 73.9%) were observed in the NCPAP arm (p<.001).

Figure 1. KM FEF probability

Conclusions

The impact of NCPAP and HHHFNC on FI was similar despite differing working mechanisms. Clinicians should tailor respiratory care by choosing and switching between the two techniques based on their respiratory effectiveness and patient compliance, regardless of the possible effect on FI.