בס"ד

Is any one aware of clinical trials of gut priming with TPN for ELBW infants?

Regards

Yoram Bental M.D.

Neonatology

Laniado Hospital

Israel

Hi Yoram

Your question is very interesting even I have no answer for it. But, I've asked, recently, Prof Simon Newell, one of the leading persons in premature nutrition about that; I use, with my colleagues, in our NICU to prime ELBW with TPN keeping in mind that osmolarity may be deleterious. With this precaution and progressing very carefully, we don't have experienced till now any NEC. So, Simon was very surprised and find the idea very interesting. To my knowledge and of Simon also, there is no RCT about that. Probably, Simon will inform you more about that (he's working in Leeds). WHy don't you launch this kind of trial?

Hope I've been a little bit helpful.

Friendly

Hi Yoram

Your question is very interesting even I have no answer for it. But, I've asked, recently, Prof Simon Newell, one of the leading persons in premature nutrition about that; I use, with my colleagues, in our NICU to prime ELBW with TPN keeping in mind that osmolarity may be deleterious. With this precaution and progressing very carefully, we don't have experienced till now any NEC. So, Simon was very surprised and find the idea very interesting. To my knowledge and of Simon also, there is no RCT about that. Probably, Simon will inform you more about that (he's working in Leeds). WHy don't you launch this kind of trial?

Hope I've been a little bit helpful.

Friendly

Thanks for your reply!!!

Y Bental M.D.

I would be very concerned about the issues of serum osmolality. The usual peripheral TPN solution can have an osmolar concentration that is three times that of breastmilk or formula. I am aware of trials of amniotic fluid as trophic feeds. Perhaps an interesting twist would be to attempt trophic feeds with a "synthetic" formulation that would simulate the trophic exposure in utero.

Mitchell Goldstein, M.D.

In our units at Karolinska we use breastmilk (donated or the mother's) for so-called trophic feeding. Usually we start during the first days of life, with 0.5-1.0 ml every 3-4 hour.

Mininmal Enteral Nutrition or trophic feeding is practised in many NICU units all over India.Early introduction of oral feeding accelerates the transition time from tube to all oral feeding. This not only allows earlier attainment of all oral feeding, but it also provides practice opportunities that enhance the oral motor skills necessary for safe and successful feeding.

Minimal Entetral Nutrition (MEN)should be avoided in infants with

severe hemodynamic instability,

suspected or confirmed NEC, evidence of

intestinal obstruction/ perforation or

paralytic ileus.

Recommended volume is 10-15 ml/kg/day. This should be divided into equal aliquots and administered by gavage feeding in a 3-6 hourly feeding schedule.

In VLBW infants born with antenatal diagnosis of problems in umbilical arterial blood flow (reverse or absent end diastolic flow), MEN can possibly be delayed for 2 to 3 days.

Advancement of feeds should also be slow and carefully monitored in these infants.

Monitoring

The infant should be monitored for any evidence of feed intolerance including abdominal girth, gastric residuals or clinical signs of necrotizing enterocolitis (NEC).

If the abdominal girth has increased by 2 cm, gastric residual volume (GRV) should be checked.

Feeding should be stopped in the presence of significant aspirate (>25% of feed or >3ml whichever is more) and/ or bilious or blood stained aspirates.