Association of Bolus Feeding With Splanchnic and Cerebral Oxygen Utilization Efficiency Among Premature Infants With Anemia and After Blood Transfusion

Abstract

IMPORTANCE The pathogenesis of transfusion-associated necrotizing enterocolitis remains elusive. Splanchnic hypoperfusion associated with packed red blood cell transfusion (PRBCT) and feeding has been implicated, but studies of splanchnic tissue oxygenation with respect to feeding plus PRBCT are lacking. OBJECTIVE To investigate the oxygen utilization efficiency of preterm gut and brain challenged with bolus feeding during anemia and after transfusion using near-infrared spectroscopy. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study conducted from September 1, 2014, to November 30, 2016, at a tertiary neonatal intensive care unit included 25 hemodynamically stable infants with gestational age less than 32 weeks, birth weight less than 1500 g, and postmenstrual age younger than 37 weeks. Data analysis was performed from August 1, 2017, to October 31, 2018. EXPOSURES Infants received PRBCT (15 mL/kg for 4 hours) and at least 120 mL/kg daily of second hourly bolus feedings. MAIN OUTCOMES AND MEASURES Splanchnic fractional tissue oxygen extraction (FTOEs) and cerebral fractional tissue oxygen extraction (FTOEc) measures were made during 75-minute feeding cycles that comprised a 15-minute preprandial feeding phase (FP0) and 4 contiguous 15-minute postprandial feeding phases (FP1, FP2, FP3, and FP4; each 15 minutes long). The intraindividual comparisons of feeding-related changes were evaluated during the pretransfusion epoch (TE0: 4 hours before onset of transfusion) and 3 TEs after transfusion (TE1: first 8 hours after PRBCT completion; TE2: 9-16 hours after PRBCT completion; and TE3: 17-24 hours after PRBCT completion). RESULTS Of 25 enrolled infants (13 [52%] female; median birth weight, 949 g [interquartile range {IQR}, 780-1100 g]; median gestational age, 26.9 weeks [IQR, 25.9-28.6 weeks]; median enrollment weight, 1670 g [IQR, 1357-1937 g]; and median postmenstrual age, 34 weeks [IQR, 32.9-35 weeks]), 1 infant was excluded because of corrupted near-infrared spectroscopy data. No overall association was found between FTOEs and FPs in a multivariable repeated-measures model that accounted for transfusion epochs (primary analysis approach) (FP0: mean estimate, 11.64; 95% CI, 9.55-13.73; FP1:

Feeding Strategies in Preterm Very Low Birth-Weight Infants

“…Feeding during transfusions may promote GI tract vulnerability by increasing the risk of tissue hypoxia,41,50 hypoperfusion, and anemia-related mucosal inflammation 43. A recent prospective cohort study of 25 VLBW infants receiving at least 120 mL/kg/d of feeds found insufficient postprandial mesenteric oxygen utilization for 8 hours following a transfusion 51…”

Hierarchical improvement of regional tissue oxygenation after packed red blood cell transfusion

“…The physiologic buffer to secure cerebral oxygenation, with the trade-off of continued splanchnic tissue hypoxia in the immediate post-transfusion period may be a factor in the pathogenesis of TANEC. Splanchnic susceptibility may be further exacerbated by other factors, including storage RBC lesion that prevents effective oxygen offloading [ 41 ] and the negative effect of continued feeding during and immediately after PRBCT [ 23 , 42 – 45 ]. The median (IQR) age of transfused packed red blood cells was 13 (4–24) days.…”

“…The methodology was similar, and many of the participants were included in the previously published study [ 23 ]. This prospective observational study was conducted in the neonatal intensive care at Nepean Hospital, Australia, (Sep 2014- Nov 2016)—Eligible participants included: gestation <32 weeks; birth weight <1500 grams (g); postmenstrual age <37 weeks; tolerating enteral feed volume ≥120 millilitres/kilogram/day (mL/Kg/day); hemodynamically stable and receiving elective PRBCT to treat anemia of prematurity.…”

Regional tissue oxygenation and conventional indicators of red blood cell transfusion in anaemic preterm infants

“…The primary study evaluated cerebral and splanchnic oxygenation associated with PRBCT and feeding. 25 The study protocol including parental consent was approved by the human research ethics committee, Nepean Blue Mountain Local Health Committee (Approval number: Study 12/67 - HREC/12/NEPEAN/148). The study was conducted after written, informed consent of parents, as approved by the human research ethics committee, Nepean Blue Mountain Local Health Committee.…”