Transcript Thickened Feedings for Premature Infants in the NICU

Thickened Feedings for
Premature Infants
in the NICU
Erin Pryor, MPH, RD, LD
April 12, 2012
ONN Spring Meeting
Columbus, Ohio
History of Thickening
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Feeds
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Thickening of infant formulas for treatment of GER
for > 50 years
- cereal, rice, bean gum, pectin, cellulose
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Rationale: Thickening increases the stickiness and
weight of the feeds
- Controversial with evidence of delayed gastric
emptying
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Alternative treatment modalities
-Prone position with head at 30 degrees
-Smaller frequent feedings
-Histamine H-2 antagonists/Proton pump inhibitors
-Time
-Severe cases: surgery
1. Reviewers: Huang R-C, Forbes DA, Davies MW
http://www.nichd.nih.gov/chochrane/Huang/Huang.htm
Thickening Feeds
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Common practice yet no evidence of
effectiveness
- Lack of randomized, controlled studies of nonpharmacological management of GER
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Spontaneous resolution occurs more
frequently in premature neonates
Theoretical disadvantages
- Delayed gastric emptying
- Increased caloric density
- Constipation
Diagnostic Tests2
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pH probe test
Barium swallow study
Upper GI
Radionuclide milk scans to detect
pulmonary aspiration
2. Feed thickener for newborn infants with gastro-oesophageal reflux (Review)
The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 2009.
Simply Thick®
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Xanthan gum-based thickener used in
the management of dysphagia
– Water holding capacity of a non-starch
polysaccharide that acts as a soluble food fiber3
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Speculation from case review:
- Stimulation of an immature gut by xanthan gum4
3. Sharp K, Ward L, Cichero J, Sopade P, Halley P. Thickened fluids and water absorption in rats
and humans. Dysphagia 2007; 22: 193-203.
4. Woods, CW, Oliver T, Lewis K, Yang Q. Development of necrotizing entercolitis in premature
infants receiving thickened feeds using Simply Thick®
Case Study
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Male Premature Infant: 30+6 wks, 1500 gms @ birth
DOL 1: TPN
DOL 2: Feeds started of 20 kcal/oz EBM/SC per feeding
protocol
DOL 6: Increased to 24kcal/oz EBM/SC
DOL 7: Vits added
DOL 10: Full feeds ~150cc/kg
DOL 15: Out of EBM
DOL 46: Neosure 22kcal/oz, tolerating formula well
DOL 52: Noted “Mom feeding well, plan for DC tomorrow”
Case Study
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DOL 52 Evening: Event needing mod stim w/feeds, dusky in
color
DOL 55: Event needing vigorous stim x 2 w/ feeds
DOL 56: Event needing vigorous stim x 1 w/ feeds
DOL 57: 39+2 wks Swallow Study w/ UGI (See OT note)
Wt. 3190, 550-680cc/day
Initial Recipe: 80 ml Neosure 22kcal
10 ml sterile water
4.5 tsp Rice cereal
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~27 kcal/oz
MD documented much improved with thickened feeds
DOL 60: RN reported difficulty w/ Dr. Browns nipple, taking
less volumes and >25 minutes to feed
Case Study
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DOL 60: Tried yellow nipple with some reported improvement
DOL 61: Yellow nipple clogging. Tried Avent Bottle 1 & 2 Flow
New Recipe:
80 ml Neosure 22kcal
10 ml sterile water
3.75 tsp rice cereal
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DOL 62: New Recipe
80 ml Neosure 22kcal
10 ml sterile water
3 tsp Rice cereal
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~26kcal/oz
~25kcal/oz
DOL 67: 40+5 wks Only 1 documented event with sleeping
(self stim) in the last 5 days since thickened feeds. Infant
discharged. Formula mixing done with mom. Follow up with
high risk nutrition clinic and GI.