Slow versus rapid enteral feeding advancement in preterm newborn infants 1000–1499 g: a randomized controlled trial

Aim:  To evaluate whether preterm neonates weighing 1000–1499 g at birth receiving rapid enteral feeding advancement at 30 mL/kg/day attain full feedings (180 mL/kg/day) earlier than those receiving slow enteral feeding advancement at 20 mL/kg/day without increase in the incidence of feeding intolerance or necrotizing enterocolitis.
Methods:  A total of 100 stable intramural neonates weighing between 1000 and 1499 g and gestational age less than 34 weeks were randomly allocated to enteral feeding (expressed human milk or formula) advancement of 20 mL/kg/day (n   = 50) or 30 mL/kg/day (n   = 50).
Results:  Neonates in the rapid feeding advancement group achieved full volume feedings before the slow advancement group (median 7 days vs. 9 days) (p < 0.001), had significantly fewer days of intravenous fluids (median 2 days vs. 3.4 days) (p < 0.001), shorter length of stay in hospital (median 9.5 days vs. 11 days) (p = 0.003) and regained birth weight earlier (median 16 days vs. 22 days) (p < 0.001). There were no statistical differences in the proportion of infants with apnea, feed interruption or feed intolerance.
Conclusion:  Rapid enteral feeding advancements of 30 mL/kg/day are well tolerated by stable preterm neonates weighing 1000–1499 g.     

母乳及配方奶喂养对NICU早产儿的影响

目的分析母乳喂养对不同出生胎龄早产儿的重要性。方法 639例出生胎龄28~(+3)~36~(+6)周的早产儿中单纯母乳喂养组(亲乳母乳喂养,未添加强化剂)237例,以及单纯配方奶(液态早产奶)喂养组402例。比较喂养方式对体重增长,白蛋白(ALB)、碱性磷酸酶(ALP)水平,以及喂养不耐受发生率、坏死性小肠结肠炎(NEC)、早产儿视网膜病(ROP)等并发症发生率的影响。结果与配方奶喂养相比,母乳喂养的出生胎龄28~30周早产儿日体重增长较快,喂养不耐受、NEC患病率较低,碱性磷酸酶较高,白蛋白较低,差异有统计学意义(P0.05);贫血、ROP、BPD、院内感染患病率及住院时间的差异均无统计学意义(P0.05)。出生胎龄31~33周的早产儿母乳喂养组较配方奶组日体重增长快,喂养不耐受率低,住院时间短,碱性磷酸酶高,差异均具有统计学意义(P0.05);两组间NEC、贫血、ROP、BPD、院内感染的发生率及白蛋白的差异无统计学意义(P0.05)。出生胎龄34~36周早产儿不同喂养方式组的各项指标差异均无统计学意义(P0.05)。结论母乳喂养对出生胎龄28~33周早产儿体重的增长,喂养不耐受率的降低,住院时间的缩短以及NEC发生率的减低有重要意义。     

Very early feeding in stable small for gestational age preterm infants: a randomized clinical trial

ObjectiveTo examine the effect of initiating very early feeding on time-to-reach full feeding in stable, small for gestational age (SGA) preterm infants.MethodPreterm infants with gestational age below 37 weeks and birth weight below the 10^th percentile were randomly allocated to a very early (within 24 hours of birth) feeding regimen or delayed (after 24 hours of birth) feeding. All infants had in utero evidence of absent or reverse diastolic flow. Infants unable to start early feeding were excluded. Time-to-reach full feeding, feeding progression, and related morbidity were compared. Electrogastrography (EGG) was used to measure pre- and postprandial gastric motility on the second and seventh day after feeding initiation.ResultsSixty infants were included in the study, 30 in each group. Infants included in the very early feeding regimen achieved full enteral feeding sooner than controls (98 ± 80-157 vs. 172 ± 123-261 hours of age, respectively; p = 0.004) and were discharged home earlier (p = 0.04). No necrotizing enterocolitis (NEC) was documented in both study groups. Gastric motility was improved at day seven after feeding initiation in both study groups, with no difference between groups.ConclusionsStable SGA preterm infants on a very early feeding regimen achieved full enteral feeding and were discharged home significantly earlier than those on a delayed regimen, with no excess morbidity.     

早产儿喂养不耐受的诊治进展

虽然早产儿喂养不耐受的定义及诊断在不断地修改与完善,但迄今为止,仍缺乏统一的定义及诊断标准.有关其干预措施(包括喂养策略、母乳喂养、药物治疗等)的疗效,尚需要大量的临床随机研究去验证和评估.该文将对喂养不耐受定义、喂养策略,药物治疗等进展进行综述.     

早产儿临床流行病学研究现状

早产是当今新生儿学及围生医学研究的核心问题,近年来,早产儿发生率呈上升趋势.虽然随着现代医疗技术水平的提高,早产儿存活率亦有所提高,但众多并发症使其预后状况不佳.早产儿临床流行病学研究对临床医生提高早产儿诊疗水平有指导性意义,该文就早产发生原因、主要并发症及预防等方面的临床流行病学研究进展进行综述.     

Interventions to improve the oral feeding performance of preterm infants

Aim: Preterm infants have difficulty oral feeding. We hypothesized that a specific sucking and swallowing exercises vs. no intervention accelerate the attainment of independent oral feeding through a faster maturation of infants’ oral feeding skills (OFS). Methods: Very low birthweight infants were randomized to a control, sucking and swallowing groups. Sucking consisted of active sucking on a pacifier, and swallowing of placing a milk bolus (0.05–0.2 mL) on the tongue where the bolus rests prior to entering the pharynx. Primary outcome was days from start to independent oral feeding (SOF‐IOF). Secondary outcomes included overall transfer (OT, % volume taken/volume prescribed), proficiency (PRO, % volume taken at 5 min/volume prescribed), rate of transfer (RT, mL/min) over the entire feeding and infants’ OFS levels. OFS levels were defined by PRO and RT. Results: Days from SOF to IOF vs controls (21 ± 2) were similar for the sucking group (19 ± 2) and shorter for the swallowing group (15 ± 2; p = 0.019). Only the latter infants demonstrated more mature OFS levels than controls. Conclusion: The swallowing exercise is an efficacious intervention in facilitating the attainment of independent oral feeding, but not the sucking exercise. We speculate that the swallowing benefit resulted from an accelerated maturation of infants’ OFS levels.     

口腔运动干预改善早产儿脑功能发育的随机对照研究

目的 探讨口腔运动干预(oral motor intervention,OMI)对早产儿脑功能发育的影响.方法 采用分层随机分组方法,将112例早产儿按胎龄分为小胎龄(30～31+6周)及大胎龄(32～33+6周)两层,再随机分为对照组(分别23、22例)和干预组(分别24、23例).对照组予以常规治疗,干预组在此基础...     

Stimulation of sucking and swallowing to promote oral feeding in premature infants

AIM: To study the effect of stimulation of sucking and swallowing on weaning from nasogastric (NG) feeding and length of hospital stay in premature infants. METHOD: Randomized controlled trial with blinded evaluation. Premature infants on NG feeds and post-menstrual age (PMA) less than 36 weeks who had poor ability to suck were randomized to receive one daily session of stimulation according to Vojta or no intervention other than standard nursing care. RESULTS: Of 36 infants, 18 received stimulation and 18 were observed without intervention. Mean gestational age at birth was 32.2 weeks (SD 2.4) versus 31.4 (2.3) weeks, p = 0.27, and PMA at study entry 35.1 weeks (0.8) versus 34.4 (0.9) weeks, p = 0.01, respectively. NG feeding was discontinued at 36.8 weeks (0.9) versus 36.3 (0.9) weeks' PMA, p = 0.25, and they were discharged at 37.8 weeks (0.9) versus 37.7 (1.3) weeks, p = 0.81. CONCLUSION: The stimulation programme did not result in earlier weaning from NG feeding or earlier discharge. However, such studies may need to be large to limit the possibility of type II errors.     

静脉应用小剂量红霉素防治早产儿喂养不耐受的Meta分析

摘要 目的 对静脉应用小剂量红霉素防治早产儿喂养不耐受的疗效和安全性的相关文献进行Meta分析,为早产儿喂养不耐受的治疗提供参考依据。方法 索Cochrane图书馆、PubMed、EMBASE、在研试验数据库、中国生物医学文献数据库、中国期刊全文数据库、万方数据库和维普中文科技期刊数据库等。检索红霉素防治早产儿喂养不耐受的RCT文献。按Cochrane系统评价方法进行文献质量评价,采用RevMan 5.0.17软件进行Meta分析。结果 共纳入18篇RCT文献,文献质量评价A级1篇,B级3篇,C级14篇。共纳入1 200例早产儿。Meta分析结果显示：①达到全肠内喂养时间：红霉素预防组加权均数差值（WMD）=-4.18（95%CI：-6.29 ~-2.08）,红霉素治疗组WMD=-4.69（95%CI：-6.38～-3.00）,两组均可较早实现全肠内喂养;胎龄≤32周亚组WMD＝-5.15（95%CI：-12.60～2.30）,与对照组差异无统计学意义。剔除低质量文献行敏感度分析,WMD=-5.48（95%CI：-11.66～0.69）,红霉素治疗组与对照组差异无统计学意义。②红霉素预防组住院时间（WMD=-1.10,95%CI：-3.65～1.37）和NEC发生率（OR=1.01,95%CI：0.24～4.22）与对照组差异无统计学意义;红霉素治疗组日均体重增加（WMD= 4.29,95%CI：-2.06～10.64）和NEC发生率 （OR=0.68,95%CI：0.18～2.56）与对照组差异无统计学意义;红霉素治疗组恢复至出生体重时间（WMD=-2.45,95%CI：-2.87～-2.04）、症状消失间（WMD＝-1.22,95%CI：-1.33～-1.11）及住院时间（WMD=-9.70,95%CI：-11.92～-7.49）与对照组差异有统计学意义。结论 对于喂养不耐受高危儿及胎龄≤32周的喂养不耐受早产儿,静脉应用小剂量红霉素的证据尚不足;对于胎龄>32周的喂养不耐受早产儿,今后研究应确定是否存在一个最佳剂量以缩短静脉营养时间及住院时间,在改善喂养不耐受的症状中红霉素可能起一定的作用。     

The effect of in-hospital developmental care on neonatal morbidity,growth and development of preterm Taiwanese infants: A randomized controlled trial

Introduction

Intervention studies of developmental care for preterm infants in Western societies have shown early but unsustainable effects on child outcomes, however only a limited of studies have examined if developmental care interventions produce similar effects in Eastern cultural contexts.

Aims

To examine the effectiveness of in-hospital developmental care on neonatal morbidity, growth and development of preterm infants with very low birth weight (VLBW; birth weight < 1500 g) in Taiwan.

Methods

One hundred and seventy-eight VLBW preterm infants were randomly assigned to the clinical trial during hospitalization at three hospitals in Taiwan; the control group received five sessions of standard child-focused developmental care and the intervention group received five sessions of child- and parent-focused developmental care. Sixty-two normal term infants were also included as a comparison group. Infants were examined for morbidity, growth and developmental outcomes at term age.

Results

At study entry, more infants in the intervention group were twins or multiples than those in the control group (29% vs. 16%, p = 0.05). After adjusting for birth set, the intervention group had lower incidences of stage II–III retinopathy (odds ratio [OR] = 0.34 [95% confidence interval (CI): 0.15–0.79]; p = 0.01) and feeding desaturation (OR = 0.32 [95% CI: 0.10–1.00]; p = 0.05) and had greater daily weight gains (difference = 2.0 g/day [95% CI: 0–4.0 g/day]; p = 0.05) as compared with the control group. However, the intervention and control groups did not differ in any of the neurodevelopmental measures.

Conclusions

In-hospital developmental care has short-term benefits for Taiwanese VLBW preterm infants in reducing the risk of retinopathy and feeding desaturation as well as in enhancing weight gains at term age.     

口服消炎痛和布洛芬治疗早产儿动脉导管未闭的比较

目的：静脉注射消炎痛是早产儿动脉导管未闭的常规治疗方法,但治疗过程中常出现一些副作用,如少尿、消化道出血、脑血流灌注减少。近年来,静脉注射布洛芬已用于治疗早产儿动脉导管未闭。布洛芬治疗不会减少脑血流灌注,也不会影响胃肠道和肾脏的血流动力学。伊朗目前尚无消炎痛和布洛芬的静脉制剂供应。该研究旨在比较这两种药的口服制剂治疗早产儿动脉导管未闭的疗效和安全性。方法：36例胎龄小于34周经超声心动图确诊患有动脉导管未闭的早产儿被随机分为两组,每组18人。一组给予消炎痛口服,每次0.2 mg/kg,24 h给药 1 次,共3次。另一组给予布洛芬口服,共 3 次,间隔时间为24 h,首剂为 10 mg/kg,随后两次各 5 mg/kg。用药后观察导管闭合率、副作用、并发症及临床过程。结果：用药后布洛芬组18例患儿动脉导管都闭合（100％）,而消炎痛组18例中有15例患儿动脉导管闭合（83.3%）（P＞0.05）。两组疗效差异统计学无显著性意义。治疗前后两组的血清尿素氮和肌酐含量差异也无显著性意义。消炎痛组发生了3例（16.6%）坏死性小肠结肠炎,布洛芬组则无,差异有显著性意义 (P＜0.05)。治疗1个月后两组成活率均为 94%（17／18）。消炎痛组1例死于坏死性小肠结肠炎,布洛芬组1例死于败血症。结论：口服布洛芬治疗早产儿动脉导管未闭和口服消炎痛治疗一样有效,而且坏死性小肠结肠炎的发生率较口服消炎痛治疗低。［中国当代儿科杂志,2007,9（5）：399-403］     

早产儿喂养不耐受临床特征分析

目的：探讨早产儿喂养不耐受的临床特征,为早产儿喂养不耐受的防治提供临床依据。方法：2007年1月至2009年12月入住新疆医科大学第一附属医院的早产儿716例为研究对象,对其临床特征进行回顾性分析。结果：①716例早产儿中197例(27.5%)发生喂养不耐受,其中极低出生体重儿喂养不耐受发生比率高达77.6%。临床表现中以单纯胃潴留所占比例最高(47.2%)。②喂养不耐受出现时间集中在开始喂养后3 d内。③喂养不耐受组早产儿胎龄和出生体重低于耐受组、开奶时间晚于耐受组、早产儿合并窒息及呼吸性疾病比例高于耐受组（P＜0.05）;而民族、性别、孕母年龄、分娩方式、有无宫内窘迫两组差别无统计学意义（P＞0.05）。随着胎龄增大、出生体重增加、尽早开始喂养,早产儿喂养不耐受发生风险降低。结论：早产儿喂养不耐受的发生与患儿胎龄、出生体重、开奶时间及合并症有关。     

Characterization of the developmental stages of sucking in preterm infants during bottle feeding

It is acknowledged that the difficulty many preterm infants have in feeding orally results from their immature sucking skills. However, little is known regarding the development of sucking in these infants. The aim of this study was to demonstrate that the bottle-feeding performance of preterm infants is positively correlated with the developmental stage of their sucking. Infants' oral-motor skills were followed longitudinally using a special nipple/bottle system which monitored the suction and expression/compression component of sucking. The maturational process was rated into five primary stages based on the presence/absence of suction and the rhythmicity of the two components of sucking, suction and expression/compression. This five-point scale was used to characterize the developmental stage of sucking of each infant. Outcomes of feeding performance consisted of overall transfer (percent total volume transfered/volume to be taken) and rate of transfer (ml/min). Assessments were conducted when infants were taking 1-2, 3-5 and 6-8 oral feedings per day. Significant positive correlations were observed between the five stages of sucking and postmenstrual age, the defined feeding outcomes, and the number of daily oral feedings. Overall transfer and rate of transfer were enhanced when infants reached the more mature stages of sucking. We have demonstrated that oral feeding performance improves as infants' sucking skills mature. In addition, we propose that the present five-point sucking scale may be used to assess the developmental stages of sucking of preterm infants. Such knowledge would facilitate the management of oral feeding in these infants.     

早产儿喂养不耐受

早产儿喂养不耐受可导致早期营养不良、生长受限,对以后的行为和认知产生影响,是目前新生儿科医生面临的重要问题。喂养不耐受与早产儿胃肠功能不成熟、围生期窒息、感染等疾病因素相关。临床治疗常采用微量喂养,促胃肠动力药、口服益生菌等方法,但目前尚无统一的预防和治疗指南。     

Oral feeding in premature infants: advantage of a self-paced milk flow

An earlier study demonstrated that oral feeding of premature infants (<30 wk gestation) was enhanced when milk was delivered through a self-paced flow system. The aims of this study were to identify the principle(s) by which this occurred and to develop a practical method to implement the self-paced system in neonatal nurseries. Feeding performance, measured by overall transfer, duration of oral feedings, efficiency, and percentage of successful feedings, was assessed at three time periods, when infants were taking 1-2, 3-5, and 6-8 oral feedings/day. At each time period, infants were fed, sequentially and in a random order, with a self-paced system, a standard bottle, and a test bottle, the shape of which allowed the elimination of the internal hydrostatic pressure. In a second study, infants were similarly fed with the self-paced system and a vacuum-free bottle which eliminated both hydrostatic pressure and vacuum within the bottle. The duration of oral feedings, efficiency, and percentage of successful feedings were improved with the self-paced system as compared to the standard and test bottles. The results were similar in the comparison between the self-paced system and the vacuum-free bottle. Elimination of the vacuum build-up naturally occurring in bottles enhances the feeding performance of infants born <30 wk gestation as they are transitioned from tube to oral feeding. The vacuum-free bottle is a tool which caretakers can readily use in neonatal nurseries.     

A randomised controlled trial of delayed cord clamping in very low birth weight preterm infants

This study was carried out to assess the feasibility of late cord clamping of 45 s in preterm infants delivered mainly by caesarean section and the effects on post-partal adaptation and anaemia of prematurity. Prior to delivery, 40 infants of <33 gestational weeks were randomised to either 20 s or 45 s of late cord clamping. After the first shoulder was delivered, oxytocin was given intravenously to the mother in order to enhance placento-fetal transfusion while the infant was held below the level of the placenta. The 20 infants in group 1 (20 s) had a mean birth weight of 1070 g and a mean gestational age of 29 + 4/7 weeks versus 1190 g and 30 weeks in group 2 (45 s). On day 42 of life there were ten infants without transfusions in group 2 versus three in group 1 (P < 0.05). Out of the 20 infants in group 1, 19 and 15/19 in group 2 were delivered by caesarean section. There were no significant differences in Apgar scores, temperature on admission, heart rate, blood pressure and requirements for artificial ventilation. Conclusion Delayed cord clamping of 45 s is feasible and safe in preterm infants below 33 weeks of gestation. It is possible to perform the procedure at caesarean section deliveries and it should be performed whenever possible. It reduces the need for packed red cell transfusions during the first 6 weeks of life. Received: 10 February 2000 / Accepted: 12 April 2000