Oral feeding for infants and children receiving nasal continuous positive airway pressure and high flow nasal cannula: a systematic review.

BACKGROUND: The aim of this systematic review was to determine whether introduction of oral feeding for infants and children receiving nasal continuous positive airway pressure (nCPAP) or high flow nasal cannula (HFNC) respiratory support facilitates achievement of full oral feeding without adverse effects, compared to no oral feeding (NPO; nil per oral) on CPAP or HFNC. METHODS: A protocol was lodged with the PROSPERO International Prospective Register of Systematic Reviews. We searched Medline, Embase, CINAHL, CENTRAL and AustHealth from database inception to 10th June 2020. Study population included children (preterm to < 18 years) on nCPAP or HFNC who were orally feeding. Primary outcomes included full or partial oral feeding and oropharyngeal aspiration. Secondary outcomes examined adverse events including clinical signs of aspiration, aspiration pneumonia and deterioration in respiratory status. RESULTS: The search retrieved 1684 studies following duplicate removal. Title and abstract screening identified 70 studies for full text screening and of these, 16 were included in the review for data extraction. Methods of non-invasive ventilation (NIV) included nCPAP (n = 6), nCPAP and HFNC (n = 5) and HFNC (n = 5). A metanalysis was not possible as respiratory modes and cohorts were not comparable. Eleven studies reported on adverse events. Oral feeding safety was predominantly based on retrospective data from chart entries and clinical signs, with only one study using an instrumental swallow evaluation (VFSS) to determine aspiration status. CONCLUSIONS: Findings are insufficient to conclude whether commencing oral feeding whilst on nCPAP or HFNC facilitates transition to full oral feeding without adverse effects, including oropharyngeal aspiration. Further research is required to determine the safety and efficacy of oral feeding on CPAP and HFNC for infants and children. TRIAL REGISTRATION: PROSPERO registration number:  CRD42016039325 .

Oral Feeding for Infants and Children Receiving Nasal Continuous Positive Airway Pressure and High-Flow Nasal Cannula Respiratory Supports: A Survey of Practice.

To investigate oral-feeding practices for infants and children receiving nasal continuous positive airway pressure (nCPAP) and high-flow nasal cannula (HFNC) respiratory support. A survey was sent to Neonatal (NICU) and Paediatric Intensive Care Units (PICU) in Australia and New Zealand to explore feeding practices for infants/children receiving nCPAP and HFNC, including criteria for commencing/recommencing oral feeding, frequency of oral feeding, strategies to assist oral feeding, assessment tools, reasons for not orally feeding, existence of written guidelines and staff opinion regarding feeding safety. Seventy-seven individual survey responses were analysed from 49 units from 38 hospitals. Most units (53%) reported that infants/children are 'never or rarely' fed orally on nCPAP compared with 21% on HFNC. 2% of units 'often' feed infants on nCPAP whilst 38% 'often' feed on HFNC. Oral feeding on HFNC is more likely to occur in a NICU (100% sometimes/often) than a PICU (55% sometimes/often) setting. Only 4% of infants are often fed orally on nCPAP versus 54% on HFNC in NICUs. Eighty percent of all units reported they do not have a written policy or guideline that includes feeding recommendations for infants/children receiving non-invasive respiratory supports. Oral feeding for infants and children receiving nCPAP and HFNC is occurring in NICU and PICUs in Australia and NZ. There is varied opinion regarding the safety of oral feeding on nCPAP and HFNC. Further research is recommended, including studies with instrumental assessment of swallow safety and investigation of short and long-term feeding outcomes, to guide clinicians in this area of practice.

SuPreme Study: a protocol to study the neuroprotective potential of sulfate among very/extremely preterm infants.

INTRODUCTION: Antenatal maternal magnesium sulfate (MgSO4) administration is a proven efficacious neuroprotective treatment reducing the risk of cerebral palsy (CP) among infants born preterm. Identification of the neuroprotective component with target plasma concentrations could lead to neonatal treatment with greater efficacy and accessibility. METHODS AND ANALYSIS: This is a prospective observational cohort study, in three tertiary Australian centres. Participants are preterm infants, irrespective of antenatal MgSO4 exposure, born in 2013-2020 at 24+0 to 31+6 weeks gestation, and followed up to 2 years corrected age (CA) (to September 2023). 1595 participants are required (allowing for 17% deaths/loss to follow-up) to detect a clinically significant reduction (30% relative risk reduction) in CP when sulfate concentration at 7 days of age is 1 SD above the mean.A blood sample is collected on day 7 of age for plasma sulfate and magnesium measurement. In a subset of participants multiple blood and urine samples are collected for pharmacokinetic studies, between days 1-28, and in a further subset mother/infant blood is screened for genetic variants of sulfate transporter genes.The primary outcome is CP. Surviving infants are assessed for high risk of CP at 12-14 weeks CA according to Prechtl's Method to assess General Movements. Follow-up at 2 years CA includes assessments for CP, cognitive, language and motor development, and social/behavioural difficulties.Multivariate analyses will examine the association between day 7 plasma sulfate/magnesium concentrations with adverse neurodevelopmental outcomes. A population pharmacokinetic model for sulfate in the preterm infant will be created using non-linear mixed-effects modelling. ETHICS AND DISSEMINATION: The study has been approved by Mater Misericordiae Ltd Human Research Ethics Committee (HREC/14/MHS/188). Results will be disseminated in peer-reviewed journal publications, and provided to the funding bodies. Using consumer input, a summary will be prepared for participants and consumer groups.