Efforts toward optimal nutrition are ever present in the NICU. After the need for oxygen and ventilation, nutrition is next in the hierarchy of need. And without good nutrition, oxygenation and ventilation may become more difficult. Preterm neonates grow very fast. In utero, there are few other demands on calorie or nutritional needs with everything going to growth.
However, in the extrauterine environment, there are competing needs for nutrition as well as a requirement that the neonate take in and metabolize all the required nutrition. It is preferable to provide nutrition via the enteral route to prevent intestinal atrophy, cholestasis and other complications of a dormant gut. However, this must be balanced with the risk of necrotizing enterocolitis, reflux and other complications of enteral feeding.
There is some evidence that the use of a feeding protocol benefits the infant in various ways. Most report a significant decrease in the rate of necrotizing enterocolitis with rates decreasing as much as 75%.1-5 In addition, outcomes related to the implementation of a feeding protocol were a decrease in late-onset sepsis and fewer days to full feeds although this was not significant.3 Many studies only evaluated the effect on necrotizing enterocolitis but this is an important outcome!
So, with this evidence, it seems advisable to implement a consistent approach to feeding. The elements of a feeding protocol should include when to start feedings, what to feed, how to progress the feeds, and when to fortify in addition to a clear definition of feeding intolerance and criteria to stop, hold or slow progression of feedings. A paper by Gephart and Hanson reviews the available evidence on feeding protocols.6 They have a sample feeding protocol that includes all these elements. It is important to note though, that this sample protocol is based on various resources and has not been tested clinically in any setting. However, it is a good place to start and whenever implementing anything new, it is important to monitor outcomes. Even in cases where a feeding protocol has been implemented with documented success, this experience is not generalizable and when implemented elsewhere, results should be monitored. Most importantly, monitoring that the protocol is actually being followed as intended is paramount. Once that is established, patient outcomes such as rate of growth, late-onset sepsis, necrotizing enterocolitis, central line days, and parenteral nutrition days should be followed to ensure that the feeding protocol is successful. Monitoring and reporting these outcomes on an ongoing basis keeps the enthusiasm high to follow the protocol or make changes along the way as indicated.
One area of feeding protocols that is probably the most difficult to agree upon is the definition of feeding intolerance and what should be done about it. Moore & Wilson have published a concept analysis of feeding intolerance.7 In order to accomplish this, literature searches were performed for the elements of feeding intolerance. These included gastric residuals greater than 50% of the previous feeding, presence of abdominal distention AND emesis. However, none of these alone defines feeding intolerance but all of them together plus other signs of distress which might include lethargy, a pattern of increasing distension, respiratory distress and others not clearly defined in this concept analysis. It is just clear that feeding intolerance cannot be defined by any one sign but rather a combination of signs. Moore & Wilson suggest a gastric residual of > 50% of the previous feed, regardless of color, presence of abdominal distension and emesis, plus other signs as a feeding intolerance definition.7
Finally, the response to feeding intolerance is important and effects outcomes. If feeding intolerance is not properly recognized and responded to it could result in less weight gain or weight loss, poor neurodevelopmental outcome and/or necrotizing enterocolitis. On the other hand, if feedings are stopped with every gastric residual, every emesis, apnea, bradycardia or other non-specific sign, nutrition would be lacking, parenteral nutrition would have to take its place and other complications would increase. So, the most appropriate response must be defined. Once this response is defined, it should then be monitored to make sure that it is adhered to. I recall one unit where I worked in which it was not unusual for the covering practitioner to stop feeds during the night with some soft signs of feeding intolerance and they would be restarted immediately when the regular practitioner re-evaluated the infant in the morning. But, even with the infant missing only one or two feeds, that’s up to 25% of the total calories for the 24-hr period and if this happens too often, certainly, it can affect growth and development.
In spite of the experience published around feeding protocols, there is very little consistency between actual protocols. The most consistent is the use of human milk. Perhaps this is the most important factor in decreasing the incidence of necrotizing enterocolitis as there are also convincing studies that show a decrease in NEC when infants are fed human milk.8
A survey of NICU nurses showed that 38% of respondents did not use a protocol in their NICU and 27% of those who reported that they did use a protocol reported that it was not followed 25% of the time. This lack of adherence to the protocol makes it difficult to evaluate the overall effect. What is your experience with feeding protocols? Is one used in the unit where you work? Is it followed consistently?
1. Smith JR. Early enteral feeding for the very low birth weight infant: the development and impact of a research-based guideline. Neonatal Netw. 2005;24(4):9-19.
2. Hanson C, Sundermeier J, Dugick L, Lyden E, Anderson-Berry AL. Implementation, process, and outcomes of nutrition best practices for infants 1500 g. Nutr Clin Pract. 2011;26(5):614-624.
3. McCallie KR, Lee HC, Mayer O, Cohen RS, Hintz SR, Rhine WD. Improved outcomes with a standardized feeding protocol for very low birth weight infants. J Perinatol. 2011;31(Suppl 1):S61-S67
4. Patole SK, de Klerk N. Impact of standardised feeding regimens on incidence of neonatal necrotising enterocolitis: a systematic review and meta-analysis of observational studies. Arch Dis Child Fetal Neonatal Ed 2005;90:F147–F151.
5. Wiedmeier SE, Henry E, Baer VL, Stoddard RA, Eggert LD, Lambert DK, Christensen RD. Center differences in NEC within one health-care system may depend on feeding protocol. American Journal of Perinatology. 2008;25(1):5-11.
6. Gephart SM, Hanson CK. Preventing necrotizing enterocolitis with standardized feeding protocols. Advances in Neonatal Care. 2013;13(1):48-54.
7. Moore TA, Wilson ME. Feeding intolerance: A concept analysis. Advances in Neonatal Care. 11(3):149-154.
8. Schanler R. Outcomes of human milk-fed premature infants. Sem Perinatol. 2011;35(1):29-33.
Looking for additional reading from Sandy Beauman’s professional perspective?
View her blog entry Striving for Improvement.
Click here to read the full blog entry.