Abstract:
Babies born very and extremely preterm have an increased risk of morbidity and mortality
compared to full term babies, due to underdevelopment and complex medical complications.
As these babies have not developed the suck-breath-swallow coordination required for breastfeeding,
they are placed on intravenous nutrition almost from birth, and typically within 24 – 72
hours are started on enteral nutrition. Early initiation and more progressive enteral feeds are
supported in research; however, the use of more conservative feeding practices are still widely
prevalent. The aim of this research is to identify the factors underlying variation in practice.
The FeDEra study was a secondary analysis of the ProVIDe trial, a multicentre, double-blind,
randomised controlled trial of 434 extremely low-birthweight babies in New Zealand and Australia.
A number of neonatal, maternal, and clinical factors were analysed to identify those
which were related to enteral feeding outcomes. Enteral feeding outcomes were then analysed
to observe relationships with clinical outcomes. The NoVI survey was a 29 question survey
sent to currently practising neonatologists in level 3 neonatal intensive care units in New Zealand,
including those sites analysed in the FeDEra study. The survey focused on understanding
the beliefs underpinning enteral feeding practice for very low-birthweight babies.
Significant variation in feeding outcomes was identified in the FeDEra study. For all enteral
feeding measures, the NICU site was significantly associated with feeding outcome. Adjusted
analysis showed site 7 took 1.1 days (95 % CI 0.2, 2.1; p= 0.008) longer than site 1, 1.1 days
(95 % CI 0.2, 1.9; p= 0.004) longer than site 5 in introducing enteral feeds. Significant differences
between sites for mean volume was detected in weeks 1 – 4 after birth, where the percentage
of babies who achieved full enteral feeds within 14 days after birth ranged from 30 – 75% depending on NICU site. The use of fortified breastmilk feeds was also highly variable,
with site 7 only using fortifier for one baby. Although 100 % of respondents in the NoVI
survey identified the presence of an up-to-date written protocol for enteral feeding, the survey
also identified significant variation in feeding practice across and within NICU sites. Full enteral
feed volumes ranged between 150 – 180 mL.Kg-1.d-1, and only two sites showed unanimous
responses. Although only two sites reported routine gastric aspirate measurement (35 %),
88 % of respondents identified that some gastric aspirate measurement would lead to a decrease
or withholding of feeds. The senior medical officer was perceived to play the most important
role in determining feeding decisions.
Although there is evidence to support early and more progressive enteral feeds, hospital policies
and practices as well as personal beliefs significantly contribute to variation in enteral
feeding. The development of national consensus guidelines may mitigate some of this variation
seen both across and within sites.