BackgroundEarly introduction of enteral nutrition (EN) in postoperative infants improves intestinal adaptation, reducing the risk of intestinal failure–associated liver disease (IFALD). Our objective was to determine whether guideline use reduces feeding variability and improves outcomes in the neonatal intensive care unit (NICU).MethodsIn a cohort study, surgical infants at risk for IFALD were evaluated pre and post implementation of feeding guidelines at 2 NICUs. A total of 167 guideline infants (2013–2018) were compared with 242 historical controls (2007–2013). Adherence was measured with timing and volume of initial postoperative feed. Primary outcomes were IFALD incidence and time to reach 50% and 100% of energy from EN. Secondary outcomes were parenteral nutrition (PN) days, postoperative necrotizing enterocolitis (NEC), central line–associated bloodstream infection (CLABSI), and length of stay (LOS).ResultsModerate IFALD decreased from 32% to 20% (P = .005) in the guideline group. Time to achieve 50% and 100% energy from EN was decreased from medians of 8 to 5 and 28 to 21 days, respectively (P < .001). There was an overall decrease in PN use from 41 to 29 days (P = .002), CLABSI incidence from 25% to 5% (P < .001), and LOS from 70 to 53 days (P = .030). Once stratified by diagnosis, infants with NEC showed greatest improvement and reduction in IFALD from 67% to 42% (P = .045). With no difference in postoperative NEC (P = .464).ConclusionEarly standardized postoperative EN guidelines in intestinal‐surgery infants was associated with improved outcomes, including faster achievement of feeding goals and reduced IFALD severity, especially in infants with NEC.

DBM provides comparable nutrient intake to MOM at a higher enteral feeding volume. However, both types of human milk failed to meet energy needs with standard fortification regimens.

Early reports suggested that predictive equations significantly underestimate the energy requirements of critically ill patients with coronavirus disease 2019 (COVID‐19) based on the results of indirect calorimetry (IC) measurements. IC is the gold standard for measuring energy expenditure in critically ill patients. However, IC is not available in many institutions. If predictive equations significantly underestimate energy requirements in severe COVID‐19, this increases the risk of underfeeding and malnutrition, which is associated with poorer clinical outcomes. As such, the purpose of this narrative review is to summarize and synthesize evidence comparing measured resting energy expenditure via IC with predicted resting energy expenditure determined via commonly used predictive equations in adult critically ill patients with COVID‐19. Five articles met the inclusion criteria for this review. Their results suggest that many critically ill patients with COVID‐19 are in a hypermetabolic state, which is underestimated by commonly used predictive equations in the intensive care unit (ICU) setting. In nonobese patients, energy expenditure appears to progressively increase over the course of ICU admission, peaking at week 3. The metabolic response pattern in patients with obesity is unclear because of conflicting findings. Based on limited evidence published thus far, the most accurate predictive equations appear to be the Penn State equations; however, they still had poor individual accuracy overall, which increases the risk of underfeeding or overfeeding and, as such, renders the equations an unsuitable alternative to IC.

Background. Optimal nutrition for very low birth weight (VLBW, <1500 grams) preterm infants is critical in the neonatal period. With substantial variation in clinical practice, there is limited data on impact of early nutrition on growth and outcomes. Objective. The purpose of this study was to conduct a quality improvement project evaluating growth and clinical outcomes after implementing standardized enteral feeding guidelines for preterm infants. Methods. Evidence based clinical practice feeding guidelines were developed and implemented for VLBW infants in NICU. Primary outcome measures were (1) the rate of early initiation of enteral feeds (< 5 days of life) and (2) growth outcomes as measured by weight and head circumference from birth to discharge. Secondary outcome measures were total TPN days and rate of cholestasis. Retrospective data prior to initiation of guidelines were compared with data from post-implementation period in logistic and linear regression models. Results. Pre and post-implementation cohorts consisted of 121 and 114 VLBW infants respectively. Standardized guidelines resulted in early initiation of enteral feeds by day 5 (OR = 3.57; p< 0.001) and an average weight gain >20gm/day during hospital stay (OR= 1.89; p< 0.05). In both groups there was early achievement of full feeds with early initiation of feeds (p<0.001). Similarly, infants who initiated early enteral feeds were less likely to develop cholestasis (direct bilirubin >2 mg/ dl) (p<0.01) Conclusions. Consistent and standardized approach to early nutrition in VLBW infants results in improved growth and clinical outcomes with less duration of TPN and decreased rate of cholestasis.

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Background: We evaluated tolerance of hydrolyzed liquid protein (LP) supplement added to fortified human milk (HM) to optimize protein intake in preterm infants. Methods: A prospective observational study of 31 subjects compared with 31 historic controls, receiving mothers own milk (MOM) and/or donor milk (DM) to assess LP tolerance, growth, and risk for morbidities was conducted. Milk was analyzed for nutrient content. Feeding intolerance, defined as cessation of feedings for ࣙ48 hours, abdominal distension and/or residuals, necrotizing enterocolitis (NEC), and metabolic acidosis were used to assess safety, while weight and head circumference (HC) were used to evaluate growth. Results: LP added to powder-fortified HM had no impact on feeding intolerance and NEC. Biochemical parameters showed no metabolic acidosis: blood urea nitrogen levels (first week: median, 13 mg/dL; interquartile range [IQR], 9-16; last week: median, 13 mg/dL; IQR, 10.3-14; P = .94), bicarbonate levels (first week: median, 26.3 mEq/L; IQR, 24-28; last week: median, 28 mEq/L; IQR, 26.3-29.8; P = .10), and pH levels (first week: median, 7.4; IQR, 7.3-7.4; last week: median, 7.4; IQR, 7.37-7.40; P = .5). Weight and HC were not statistically significant. HM analysis showed lower protein and caloric content, respectively (MOM: 0.88 vs DM: 0.77 g/100 mL; P < .0001 and MOM: 18.68 vs DM: 17.96 kcal/oz; P = .02). Conclusions: Hydrolyzed LP is well tolerated in preterm infants with no difference in growth rates. Clinicians should focus on the need to maximize both protein and energy to optimize growth. (Nutr Clin Pract. 2019;34:450-458) Keywords enteral nutrition; human milk; infant; protein supplement From the

Objective To determine the effectiveness of liquid human milk fortifiers (HMFs) derived from exclusive HM or hydrolyzed protein on growth, necrotizing enterocolitis (NEC), or late‐onset sepsis in North American very low‐birth‐weight (VLBW) infants compared with powder HMFs (control). Methods Prospective trials published between 2009 and 2020 were systematically reviewed, and meta‐analysis was conducted by using a random‐effects model. Results Five studies were identified for up to 591 participants across 39 centers. Study treatments included whey or casein hydrolysate HMF and exclusive HM HMF. Infants fed whey or casein hydrolysate HMF had growth differences compared with the control. No differences were found across treatments in regard to NEC or sepsis. Conclusion Very low‐quality evidence suggests greater linear growth in VLBW infants fed whey hydrolysate liquid HMF, as well as greater weight gain in those fed casein hydrolysate HMF, compared with the control. Additional prospective, multicenter randomized controlled trials are needed to confirm these estimates because of sparsity of evidence. There is insufficient evidence to support HMF decisions regarding NEC or late‐onset sepsis prophylaxis.

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