Enteral feed advancement in IUGR and/or centralization

[Flavio Martins]

Hi!

I'd like to know what is your experience in enteral feeding advance in preterm with IUGR or centralization?

It's well known that a faster incremention in enteral volumes provides faster achievement of full volume without worst outcomes (https://www.nejm.org/doi/full/10.1056/NEJMoa1816654). But, in preterm with IUGR it's very frequent feeding intolerance, even with MOM or DM. Do you use a diferent strategy? 

Thank you for your attention!

[Stefan Johansson]

Hi Flavio, sorry no other had given their input yet, but here's mine: per our feeding guideline, feeds are advanced w 20-40 ml/kg/d, and of course tailored per tolerance and infant. The more immature and IUGR, we are def in the lower range or even below it, at least the first few days.

So, practically speaking, we are more careful with IUGR infants, but how it is actually done depends on both baby and team

 

[Flavio Martins]

Thank you..

Although I haven't found much of a evidence for this approach, we do the same here..

 

[Vicky Payne]

In our unit we categorise our babies into high-risk, medium-risk and low-risk for nutritional management of PN and enteral feeding. High risk, severe IUGR with absent or reversed EDF babies would be 10-20mls/kg/day.  We also have guidance about how to manage abdominal distension and aspirates- but there is a definite movement in the research community around stopping "routine" checking of gastric residuals....

[carlosaldana]

We all are aware ,that babies with severe IUGR have a higher risk of NEC, but I think,according  to our experience,that this is probably a different type of NEC with different epidemiology and pathophysiology. for example,the onset of the disease tends to be very early, when the baby is NPO or in minimal enteral feedings. I have the impression enteral nutrition does not play a major role in these cases,as in "classical" NEC. we do not have a special protocol for these babies. in the studies of slow vs fast feeds advancements, babies with severe IUGR are frequently included. there is a single study that I remember where they compare IUGR infants with a control group, with the same feeding protocol. the incidence of nec was not different. Greetings   

[Bernhard Bungert]

On 10/15/2021 at 8:10 PM, carlosaldana said:

We all are aware ,that babies with severe IUGR have a higher risk of NEC, but I think,according  to our experience,that this is probably a different type of NEC with different epidemiology and pathophysiology. for example,the onset of the disease tends to be very early, when the baby is NPO or in minimal enteral feedings. I have the impression enteral nutrition does not play a major role in these cases,as in "classical" NEC. we do not have a special protocol for these babies. in the studies of slow vs fast feeds advancements, babies with severe IUGR are frequently included. there is a single study that I remember where they compare IUGR infants with a control group, with the same feeding protocol. the incidence of nec was not different.

We Start with high IV protein on first Day, give colostrum as much as avaible. Give oral G5% til Mom is avaible. Aditionally Start at the second Day of life with rectal enema (til 10 ml warmed NaCl0,9% /kg) so we Thing we prevent mucus plug. Seldom we use Erythromycin (4 mg/kg 3 td). We ignore gastric residuals after Day 7. (No evidence, but good expierence). No abd. Massage. Low flow Natal canula.

[chandas]

We would use the fast (30 ml/kg/d increment) regimen in the SIFT trial even for babies with IUGR but would adopt the standard (18 ml/kg/d increment) for those with absent or reversed end-diastolic flow or raised blood lactate in first postnatal day. If there is feed intolerance, then use of low dose erythromycin as prokinetic usually helps to maintain/advance feeds.

[carlosaldana]

another point of personal interest is highlighted by Bernhard: the frequent of rectal enemas in these babies. Are there any data to support this practice?

Thank you 

[Flavio Martins]

On 10/22/2021 at 1:07 PM, carlosaldana said:

another point of personal interest is highlighted by Bernhard: the frequent of rectal enemas in these babies. Are there any data to support this practice?

Thank you 

I've read an article about Japanese management of extremely preterm infants and they use retal enemas until the meconium passes.. but, I haven't found strong evidence. Does any of you use It?