Education of family members to support weaning to solids and nutrition in infants born preterm (Review) Education of family members to support weaning to solids and nutrition in infants born preterm (Review)

BackgroundWeaning refers to the period of introduction of solid food to complement breast milk or formula milk. Preterm infants are known to acquire extrauterine growth restriction by the time of discharge from neonatal units. Hence, the postdischarge and weaning period are crucial for optimal growth. Optimisation of nutrition during weaning may have long‐term impacts on outcomes in preterm infants. Family members of preterm infants may require nutrition education to promote ideal nutrition practices surrounding weaning in preterm infants who are at high risk of nutritional deficit.ObjectivesTo investigate the role of nutrition education of family members in supporting weaning in preterm infants with respect to their growth and neurodevelopment compared with conventional management.Search methodsWe used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 5), MEDLINE via PubMed (1966 to 26 June 2018), Embase (1980 to 26 June 2018), and CINAHL (1982 to 26 June 2018). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi‐RCTs.Selection criteriaRCTs and quasi‐RCTs were eligible for inclusion if they examined the effects of nutrition education of family members as compared to conventional management for weaning of preterm infants up to one year of corrected gestational age. We defined prematurity as less than 37 completed weeks of gestation.Data collection and analysisAt least two review authors independently screened potential studies for inclusion and planned to identify, extract data, and assess the quality of eligible studies. We resolved any differences in opinion through discussion with a third review author and consensus among all three review authors.Main resultsNo eligible trials looking at the impact of nutrition education of family members in weaning of preterm infants fulfilled the inclusion criteria of this systematic review. Two studies investigating the ideal timing for weaning in premature infants reported conflicting results,Authors' conclusionsWe were unable to assess the impact of nutrition education of family members in weaning of preterm infants as there were no eligible studies. This may be due to the lack of evidence to determine the ideal weaning strategies for preterm infants with regards to the time of initiating weaning and type of solids to introduce. Trials are needed to assess the many aspects of infant weaning in preterm infants. Long‐term neurodevelopment and metabolic outcomes should also be assessed in addition to growth parameters

Airflow dispersion during common neonatal resuscitation procedures: A simulation study

BackgroundAerosol generating medical procedures (AGMPs) are common during newborn resuscitation. Neonates with respiratory viruses such as severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection may pose a risk to healthcare workers. International guidelines differ on methods to minimize the risk due to limited data.ObjectiveWe examined the expiratory airflow dispersion during common neonatal resuscitation AGMPs using infant simulators.MethodsExpiratory airflow dispersion in term and preterm manikins was simulated (n = 288) using fine particle smoke at tidal volumes of 5 ml/kg. Using ImageJ, we quantified dispersion during common airway procedures including endotracheal tube (ETT) and T‐piece ventilation.ResultsMaximal expiratory dispersion distances for the unsupported airway and disconnected uncuffed ETT scenarios were 30.2 and 22.7 cm (term); 22.1 and 17.2 cm (preterm), respectively. Applying T‐piece positive end expiratory pressure (PEEP) via an ETT (ETTPEEP) generated no expiratory dispersion but increased tube leak during term simulation, while ventilation breaths (ETTVENT) caused significant expiratory dispersion and leak. There was no measurable dispersion during face mask ventilation. For term uncuffed ETT ventilation, the particle filter eliminated expiratory dispersion but increased leak. No expiratory dispersion and negligible leak were observed when combining a cuffed ETT and filter. Angulated T‐piecesgenerated the greatest median dispersion distances of 35.8 cm (ETTPEEP) and 23.3 cm (ETTVENT).ConclusionsAirflow dispersion during neonatal AGMPs is greater than previouslypostulated and potentially could contaminate healthcare providers during resuscitation of infants infected with contagious viruses such as SARS‐CoV‐2. It is possible to mitigate this risk using particle filters and cuffed ETTs. Applicability in the clinical setting requires further evaluation

Feed thickener for infants up to six months of age with gastro-oesophageal reflux (Review)

Background Gastro-oesophageal reflux (GOR) is common in infants, and feed thickeners are often used to manage it in infants as they are simple to use and perceived to be harmless. However, conflicting evidence exists to support the use of feed thickeners. Objectives To evaluate the use of feed thickeners in infants up to six months of age with GOR in terms of reduction in a) signs and symptoms of GOR, b) reflux episodes on pH probe monitoring or intraluminal impedance or a combination of both, or c) histological evidence of oesophagitis. Search methods We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 2), MEDLINE via PubMed (1966 to 22 November 2016), Embase (1980 to 22 November 2016), and CINAHL (1982 to 22 November 2016). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials. Selection criteria We included randomised controlled trials if they examined the effects of feed thickeners as compared to unthickened feeds (no treatment or placebo) in treating GOR in term infants up to six months of age or six months of corrected gestational age for those born preterm. Data collection and analysis Two review authors independently identified eligible studies from the literature search. Two review authors independently performed data extraction and quality assessments of the eligible studies. Differences in opinion were resolved by discussion with a third review author, and consensus was reached among all three review authors.We used the GRADE approach to assess the quality of the evidence. Main results Eight trials recruiting a total of 637 infants met the inclusion criteria for the systematic review. The infants included in the review were mainly formula-fed term infants. The trials were of variable methodological quality. Formula-fed term infants with GOR on feed thickeners had nearly two fewer episodes of regurgitation per day (mean difference -1.97 episodes per day, 95% confidence interval (CI) -2.32 to -1.61; 6 studies, 442 infants, moderate-certainty evidence) and were 2.5 times more likely to be asymptomatic from regurgitation at the end of the intervention period (risk ratio 2.50, 95% CI 1.38 to 4.51; number needed to treat for an additional beneficial outcome 5, 95% CI 4 to 13; 2 studies, 186 infants, low-certainty evidence) when compared to infants with GOR on unthickened feeds. No studies reported failure to thrive as an outcome. We found low-certainty evidence based on 2 studies recruiting 116 infants that use of feed thickeners improved the oesophageal pH probe parameters of reflux index (i.e. percentage of time pH < 4), number of reflux episodes lasting longer than 5 minutes, and duration of longest reflux episode. No major side effects were reported with the use of feed thickeners. Information was insufficient to conclude which type of feed thickener is superior. Authors’ conclusions Gastro-oesophageal reflux is a physiological self resolving phenomenon in infants that does not necessarily require any treatment. However, we found moderate-certainty evidence that feed thickeners should be considered if regurgitation symptoms persist in term bottle-fed infants. The reduction of two episodes of regurgitation per day is likely to be of clinical significance to caregivers. Due to the limited information available, we were unable to assess the use of feed thickeners in infants who are breastfeeding or preterm nor could we conclude which type of feed thickener is superior

Education of family members to support weaning to solids and nutrition in later infancy in term-born infants

Review questionWe reviewed the evidence for effects of nutrition education about appropriate feeding practices during weaning on growth and development in children born at term gestation.BackgroundAround the world, over 150 million children are undernourished and over 42 million are overweight and obese. Providing families with appropriate education about feeding practices during weaning may help to optimise nutrition while helping to protect children who are at risk of undernutrition, as well as those susceptible to being overweight and obese.Study characteristicsWe examined research published up to December 2019 and found 21 clinical trials recruiting 14,241 babies. The nutrition education provided in all included studies, whereby analysis could be pooled together, was aimed at reducing the risk of undernutrition in childhood. Five studies were undertaken in high-income countries, but the findings reported could not be included and pooled together in this review.Key resultsWe found that giving nutrition education about appropriate feeding practices during weaning to families in low- to moderate-income settings may improve weight and height at 12 months of age. We are very uncertain about the effects of nutrition education on children's development and risk of anaemia at one year of age, as only two studies reported each of these outcomes. Therefore, these results are described only in the text. We did not find any studies that assessed the effects of nutrition education on children's risk of overweight and obesity and reported outcomes that could be pooled together in this review.Certainty of evidenceThe certainty of evidence for the reduction in risk of childhood undernutrition with nutrition education is low to moderate at best due to limitations in study design and differences among the studies included in our review. The amount of improvement in growth noted is small and of unclear clinical significance. More long-term studies are needed to see if this improvement continues into later life, leading to bigger improvements. We rated the certainty of evidence for other outcomes included in this study as low due to the limited number of included studies.Further research is needed to determine whether nutrition education can reduce risks of overnutrition and obesity in children

Observational cohort study of changing trends in non-invasive ventilation in very preterm infants and associations with clinical outcomes

Objective: To determine the change in non-invasive ventilation (NIV) use over time in infants born at <32 weeks’ gestation and the associated clinical outcomes.Study design: Retrospective cohort study using routinely recorded data from the National Neonatal Research Database of infants born at <32 weeks admitted to neonatal units in England and Wales from 2010 to 2017.Results: In 56 537 infants, NIV use increased significantly between 2010 and 2017 (continuous positive airway pressure (CPAP) from 68.5% to 80.2% in 2017 and high flow nasal cannula (HFNC) from 14% to 68%, respectively) (p<0.001)). Use of NIV as the initial mode of respiratory support also increased (CPAP, 21.5%–28.0%; HFNC, 1%–7% (p<0.001)).HFNC was used earlier, and for longer, in those who received CPAP or mechanical ventilation. HFNC use was associated with decreased odds of death before discharge (adjusted OR (aOR) 0.19, 95% CI 0.17 to 0.22). Infants receiving CPAP but no HFNC died at an earlier median chronological age: CPAP group, 22 (IQR 10–39) days; HFNC group 40 (20–76) days (p<0.001). Among survivors, HFNC use was associated with increased odds of bronchopulmonary dysplasia (BPD) (aOR 2.98, 95% CI 2.81 to 3.15) and other adverse outcomes.Conclusions: NIV use is increasing, particularly as initial respiratory support. HFNC use has increased significantly with a sevenfold increase soon after birth which was associated with higher rates of BPD. As more infants survive with BPD, we need robust clinical evidence, to improve outcomes with the use of NIV as initial and ongoing respiratory support

Feed thickener for infants up to six months of age with gastro-oesophageal reflux (Review)

Background Gastro-oesophageal reflux (GOR) is common in infants, and feed thickeners are often used to manage it in infants as they are simple to use and perceived to be harmless. However, conflicting evidence exists to support the use of feed thickeners. Objectives To evaluate the use of feed thickeners in infants up to six months of age with GOR in terms of reduction in a) signs and symptoms of GOR, b) reflux episodes on pH probe monitoring or intraluminal impedance or a combination of both, or c) histological evidence of oesophagitis. Search methods We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 2), MEDLINE via PubMed (1966 to 22 November 2016), Embase (1980 to 22 November 2016), and CINAHL (1982 to 22 November 2016). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials. Selection criteria We included randomised controlled trials if they examined the effects of feed thickeners as compared to unthickened feeds (no treatment or placebo) in treating GOR in term infants up to six months of age or six months of corrected gestational age for those born preterm. Data collection and analysis Two review authors independently identified eligible studies from the literature search. Two review authors independently performed data extraction and quality assessments of the eligible studies. Differences in opinion were resolved by discussion with a third review author, and consensus was reached among all three review authors.We used the GRADE approach to assess the quality of the evidence. Main results Eight trials recruiting a total of 637 infants met the inclusion criteria for the systematic review. The infants included in the review were mainly formula-fed term infants. The trials were of variable methodological quality. Formula-fed term infants with GOR on feed thickeners had nearly two fewer episodes of regurgitation per day (mean difference -1.97 episodes per day, 95% confidence interval (CI) -2.32 to -1.61; 6 studies, 442 infants, moderate-certainty evidence) and were 2.5 times more likely to be asymptomatic from regurgitation at the end of the intervention period (risk ratio 2.50, 95% CI 1.38 to 4.51; number needed to treat for an additional beneficial outcome 5, 95% CI 4 to 13; 2 studies, 186 infants, low-certainty evidence) when compared to infants with GOR on unthickened feeds. No studies reported failure to thrive as an outcome. We found low-certainty evidence based on 2 studies recruiting 116 infants that use of feed thickeners improved the oesophageal pH probe parameters of reflux index (i.e. percentage of time pH < 4), number of reflux episodes lasting longer than 5 minutes, and duration of longest reflux episode. No major side effects were reported with the use of feed thickeners. Information was insufficient to conclude which type of feed thickener is superior. Authors’ conclusions Gastro-oesophageal reflux is a physiological self resolving phenomenon in infants that does not necessarily require any treatment. However, we found moderate-certainty evidence that feed thickeners should be considered if regurgitation symptoms persist in term bottle-fed infants. The reduction of two episodes of regurgitation per day is likely to be of clinical significance to caregivers. Due to the limited information available, we were unable to assess the use of feed thickeners in infants who are breastfeeding or preterm nor could we conclude which type of feed thickener is superior

Impact of postnatal dexamethasone timing on preterm mortality and bronchopulmonary dysplasia: a propensity score analysis

Introduction Postnatal dexamethasone (PND) is used in high-risk preterm infants after the first week of life to facilitate extubation and prevent bronchopulmonary dysplasia (BPD) but the optimal treatment timing remains unclear.Objective Explore the association between the timing of PND commencement with mortality and respiratory outcomes.Methods Retrospective National Neonatal Research Database study of 84,440 premature infants born below 32 weeks of gestational age from 2010–2020 in England and Wales. Propensity score weighting analysis was used to explore the impact of PND commenced at three timepoints (two to three weeks (PND2/3), four to five weeks (PND4/5) and after five weeks (PND6+) of chronological age) on the primary composite outcome of death before neonatal discharge and/or severe BPD (defined as respiratory pressure support at 36 weeks) alongside other secondary respiratory outcomes.Results 3469 infants received PND. Compared to PND2/3, infants receiving PND6+ were more likely to die and/or develop severe BPD (OR 1.68, 95% CI 1.28–2.21), extubate at later postmenstrual age (mean difference 3.1 weeks, 95% CI 2.9–3.4), potentially require respiratory support at discharge (OR 1.34, 95% CI (1.06–1.70), but had lower mortality before discharge (OR 0.38, 95% CI 0.29–0.51). PND4/5 was not associated with severe BPD or discharge respiratory support.Conclusion PND treatment after five weeks of age was associated with worse respiratory outcomes although residual bias cannot be excluded. A definitive clinical trial to determine the optimal PND treatment window, based on early objective measures to identify high-risk infants, is needed

User-centred design of patient information for hospital admissions and patient experience

This paper describes a user-centred approach to information design in an Acute Medical Unit (AMU). It presents a process for inclusion of clinical staff, nurses and patients in the design of information to be used for improving the efficiency of patient admissions to the wards and to increase patient understanding and satisfaction with the service. Human factors expertise was sought to assess the environment, admissions to the AMU and patient clerking by junior doctors. The paper outlines the challenges of designing for multiple users with varying needs and the intricacies of information design and provision when developing a patient leaflet for use in the NHS.</p