PO-0581 Nutrition During Therapeutic Hypothermia In Neonates

Abstract

Adequate nutrition during therapeutic cooling for ischaemic injury in the newborn is important in minimising long-term neurological morbidity.1 National TOBY guidelines suggest enteral feeds may be ‘cautiously introduced’ during cooling following the correction of biochemical and metabolic disturbances.2 However, it has been suggested that neonates exposed to hypoxic injury are at increased risk of developing necrotizing enterocolitis (NEC) and so feeds should be withheld until re-warming.3 A national survey was performed to gain insight into current approaches towards enteral feeding during therapeutic cooling. Methods Hospitals were contacted by telephone and asked standardised questions about nutritional practice during cooling. 42 of the 47 units to provide cooling in the UK supplied information. Results 67% of hospitals had no guidelines or had guidelines that failed to provide information with regards to starting enteral feeds during cooling. 79% do not give enteral nutrition during cooling. Of these, 24% of guidelines cited risk of NEC/GI complications as justification. 70% offered no reasoning for the recommendation. In these units, 45% began patients on TPN (± lipids), while 55% provide only IV fluids. No units give full enteral nutrition, however 21% of units provide trophic feeds, preferentially using expressed breast milk most frequently at a rate of 1 mL 1–4 hly, with supplemental IV fluids and no adjunctive TPN. Conclusion This survey concludes that there is no uniform approach to nutrition during therapeutic cooling in neonates within the UK. Further research and subsequent guideline development is essential to ensure optimal treatment is given to this patient group. References 1 JY Ting, D Manhas, SM Innis, S Albersheim, Elevated Triglycerides Levels in Two Infants With Hypoxic-ischemic Encephalopathy Undergoing Therapeutic Hypothermia and Receiving Parenteral Nutrition. JPEN J Parenter Enteral Nutr. 2013 Jul 26, Epub ahead of print 2 The UK TOBY Cooling Register – Clinician’s Handbook Available: Accessed: 07/04/2014 3 R Mosalli, Whole Body Cooling for Infants with Hypoxic-Ischemic Encephalopathy, J Clin Neonatol. 2012 Apr-Jun; 1(2): 101–106

Nutritional management in newborn babies receiving therapeutic hypothermia: two retrospective observational studies using propensity score matching

“…Furthermore, and in contrast to surveys of UK practice that suggest that enteral feeding is becoming more common during hypothermia (i.e. 29% of units in 2010 6 vs. 59% of units in 2016 3 ), we found that the proportion of babies for whom enteral feeds were introduced (31%) remained stable over the 8-year period 2010-17. These findings may be explained by incomplete survey coverage or simply reflect the difference between reported and actual practice.…”

“…For comparison, the most recent Cochrane review 2 in this area identified 11 trials and 1505 infants in total. NEC is one of the most feared complications of neonatal care 6 and is well described in case studies and single-centre series in babies with HIE. 37,38 There has been a paucity of robust incidence data because studies have hitherto been limited by small size and the use of subjective definitions of NEC.…”

“…5 A key reason for withholding enteral feeds during therapeutic hypothermia is the premise that this may reduce the risk of necrotising enterocolitis (NEC). 6 NEC is seen in term and near-term babies with HIE; however, its incidence is poorly reported. NEC was reported in only 3 of the 11 RCTs that evaluated therapeutic hypothermia in HIE and only one case was documented.…”

Survey of nutritional practices during therapeutic hypothermia for hypoxic-ischaemic encephalopathy

“… 19 Our survey illustrates widespread variability in the use of enteral and parenteral nutrition in these infants. As compared with the survey published as an abstract in 2014, 17 a significantly higher proportion of units started enteral feeds during TH. Given there are 69 NICUs that offer active TH and Allen et al had contacted only 47 units, our response rate of 71% was satisfactory compared with their rate of 89%.…”

“…16 A survey presented in 2014 reported that 21% of UK neonatal units offered trophic feeds during TH, but lacked data on when milk was introduced, milk type, volumes, frequency and advancement of feeds. 17 Given reports of the safety of small-volume enteral feeds during TH, 18 we hypothesised that rates of enteral feeding would have increased. In this study, we aimed to survey clinicians in UK neonatal units providing active TH for determining current nutritional practices during and after TH in infants with HIE.…”