Presented at the Neonatal Society 2017 Summer Meeting.
Hazeldine B1, Thyagarajan B1,2, Grant M1, Chakkarapani E1,2
1 St Michaels Hospital, University Hospitals Bristol NHS Foundation Trust
2 School of Clinical Sciences, University of Bristol
Background: Therapeutic hypothermia (TH) is the standard treatment for infants with moderate-severe hypoxic-ischaemic encephalopathy (HIE) in the UK (1). In the clinical trials of TH, infants were not fed during cooling treatment (2) due to concerns regarding gut ischaemia /injury from the hypoxic insult (3). Subsequently, cautious introduction of enteral feeding was suggested (4), and minimal enteral nutrition was reported to be safe and feasible (5). Our objective was to evaluate the current nutritional practices in UK neonatal units offering active TH for HIE.
Methods: We undertook an email survey of UK neonatal units offering active TH, identified from BAPM network pages and the TOBY register. Questions included timing of commencing enteral feeds, types of milk, volumes, frequency and parenteral nutrition (PN) use and the availability of guidelines. Ethical approval was not required. We sought responses from neonatal consultants; if unsuccessful received responses from registrar on call and research nurse. We defined enteral feeds as any milk feed given by mouth or gastric tubes. TH included day 1, 2 and 3 of cooling; rewarming included the period when infants were warmed back to normothermia. We present descriptive statistics as a percentage of units undertaking a particular practice and made some comparisons with a survey published in 2014 (6).
Results: Forty-nine responses were received (49/71, 71%). The rate of enteral feeding during TH and rewarming was 59%, 29/49. There was a significant linear trend for an increase in the proportion of units commencing enteral feeds (P =0.001) during TH. As compared to post-TH period, significantly lower milk volumes were commenced during TH, median (range) 7.5ml/kg/day (1.5-24) versus 17.5ml/kg/day (7.5-30) P=0.0004. During TH, breast milk was primarily used by 52% of units, and volumes were increased as tolerated in 55% of units. 29% of units (14/49) used PN, with 86% of those (12/14) offering enteral feeds during PN. Guidelines for feeding during TH were available in 31% of units (15/49).
Conclusion: Many neonatal clinicians offer enteral feeds predominantly using expressed breast milk, with or without PN, during TH albeit with huge variability. The heterogeneity in the nutritional practice underscores the need for assessing the safety of both enteral and parenteral nutrition during TH.
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1. NICE. Therapeutic hypothermia with intracorporeal temperature monitoring for hypoxic perinatal brain injury: NICEIPG347, May 2010
2. Azzopardi DV et al. N Engl J Med 2009;361(14):1349-58
3. Satas S et al. Biol Neonate 2003;83(2):146-56
4. UK TOBY Cooling Register Clinician’s Handbook. Version 4 ed, 2010
5. Thyagarajan B et al. Acta Paediatr 2015;104(2):146-51
6. Allen G, et al. PO-0581 Arch Dis Child 2014;99:A441-A42.