Two neos chat: How do we advance feeds in the NICU??

Lots of feeding QUESTIONS for NEONATES especially PREMATURE infants!!// Q2, Q3 or Q4 hour feeds? What are TROPHIC feeds? Fortification? How do we advance? Donor breast milk? Do we use formula? When do we fortify? Do we care about residuals? We discuss the different ways we practice in our units and our common concerns (NEC, poor growth, poor gut development, poor developmental outcomes, prolonged TPN use and need for IV access). Join our discussion, and let us know what you do in YOUR unit?!!!
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Dr. Tala is a board-certified neonatologist and has worked in busy level III and IV units for the past 15 years. She has won multiple teaching awards throughout her time as a neonatologist.
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References:
Jasani B, Patole S. Standardized feeding regimen for reducing necrotizing enterocolitis in preterm infants: an updated systematic review. J Perinatol. 2017 Jul;37(7):827-833. doi: 10.1038/jp.2017.37. Epub 2017 Mar 30. PMID: 28358382.

Anderson DM, Kliegman RM. The relationship of neonatal alimentation practices to the occurrence of endemic necrotizing enterocolitis. Am J Perinatol. 1991 Jan;8(1):62-7. doi: 10.1055/s-2007-999344. PMID: 1899016.

Stevens TP, Shields E, Campbell D, Combs A, Horgan M, La Gamma EF, Xiong K, Kacica M. Variation in Enteral Feeding Practices and Growth Outcomes among Very Premature Infants: A Report from the New York State Perinatal Quality Collaborative. Am J Perinatol. 2016 Jan;33(1):9-19. doi: 10.1055/s-0035-1554794. Epub 2015 Jun 17. PMID: 26084749.

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License code: N7BPWR9QCE5KCVLG
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*Disclaimer*: This video is intended for educational purposes only and while
we strive to give the most accurate information, errors may occur. Subsequently,
this video should not be a replacement for medical advice.

[antonrajneesh]

That was a brilliant discussion by stalwarts of neonatology... Immensely informative... Thanks loads for your efforts!

[cineMarveilles]

I clicked the like button before watching. :)) Thank you both!

[khairyelwerfeli]

27 minutes of tremendous effort and you made the topic looks easy where it’s not on books …
Thanks a lot
Could you please make and vid specific for what is the practice you do exactly about feeding again for lowering NEC in your units

[ceejayghuts]

Great discussion, insights and practices. Our unit (London, UK) does hourly feeds esp. from extreme premies starting from 0.5 hourly (12 mls/kg/day) depending on mother’s breast milk availability and this usually take days before Mum’s produces their milk. Although I do find (observational evidence only) that 2 hourly is well tolerated than hourly feeds by premies. We also have access to Donor breast milk but given only once Mum is well-informed and gives her consent. We use formula fortifier and not human fortifier (still controversial due to its lead concerns).
Thank you for your expertise and teachings, so appreciated in this part of NICU world!

[tenjutenju]

Thank you both of you for discussing on one of the crucial topic in nicu. I would like to ask a few questions related to it.
1. Can we push back the residual?
2. Can we check for residual if we are feeding via transpyloric?
3. If we are feeding continously, how frequently and when should we check for aspiration?
4. Can we put the baby in prone position when on continous feed?
5.Could you suggest which size syringe should we ideally use to feed?

Thank you once again!!

[zubairqasimrashdi]

Thanks for your educative discussion. My question what percentage of residuals would lead to interruption of feeding

[seekingpurposepartnership]

My LO born somewhere at 26w 6d could never tolerate Human Milk fortifier; no one wanted to remove it (concern for weight gain) despite an unexplainable very swollen tummy that caused lots of discomfort for weeks - I don’t know what’s the practice around this in different countries. She continued gained weight on plain breastmilk and swollen tummy resolved immediately with removal of HMF. I wonder if there are adverse effects reported with HMF but I could not believe that all the KUBs, tummy swelling, discomfort and not being able to tolerate feeds was due to this.

[seekingpurposepartnership]

It would be great if everyone was on board with breastmilk initiation. While I knew I wanted to breastfeed, I wish certain information had been made available to me by the lactation nurses. I think it took longer for my milk to come in because of the shock and confusion I was in. So discussion with the mother before delivery would be helpful - I was in the hospital for days before I had my LO - would have been a great opportunity to discuss. Also if this can really start in the OB side in the first trimester outpatient- it would be helpful. I hope to become a lactation consultant to help mothers esp. those who had babies prematurely. I think breastmilk contributed to the good outcomes she had. And I know some would argue that n = 1 but it’s the easiest thing for her to digest compared to formula.

[sunil]

Thanks Tala and Sridhar . Brilliant and very informative as usual . A question if I may. How do you manage Azotaemia post fortification. Do you fortify alternate feeds till the kidneys are able to cope with the protein load. In the our unit we are fortifying when the baby is about 80mls/kg. Another interesting comment about starting babies above 28 weeks on full feeds in India. Could you kindly point me to that paper. Many thanks again