Pauline D. Graziano APN, MS, NNP-BC

I have nothing to discloseI have nothing to disclose

• Discuss the evidence of using a standardized feeding approachstandardized feeding approach (SFA) as a method of reducing NECNEC

• Identify best-practice elements to include in a feeding “bundle” gto promote the reduction of NEC

• Review practical tips to help bring evidence to the bedside

None Zilch

• Standardization of practiced• Increased use BM

• Quicker time to i iti t / d d hiinitiate/advance and achieve full feeds

• Decreased use of• Decreased use of PN/Decreased CL days/Decreased associated y /morbidities

• Improved growth

•REDUCTION ORREDUCTION OR ELIMINATION OF NEC!

SFA + use of BM…decreased NEC 50-75%

Wiedmeier, et al (2008)

Meta-analysis 1978-2003: SFA Patole & de Klerk (2005) risk of NEC 87%. Evidence supports ANY SFA reduces NEC

No inc NEC. Safe for < 1000g (NEC 6% 3% 50%!)

Hanson, et al (2011)6% 3%= 50%!)

Dec NEC overall VLBW (18% to 3%= 83%!) & ELBW (35% to 8%= 77%!).

McCallie, et al (2011)

77%!).

SFA in ELBW- quicker to initiate, to FF75% faster, no inc in NEC

Donovan, et al (2006)

Vermont Oxford “Got Milk” group: SFA Kuzma-O’Reilly et alVermont Oxford Got Milk group: SFAdecreases NEC

Kuzma O Reilly, et al (2003)

SFA for HLHS… NEC 100% Braudis (2009)

• Standardization of practiced f d• Focused attention on feeding

and advancesI d f BM• Improved use of BM

• Standardized definition of intoleranceintolerance

Creating a Feeding Creating a Feeding B dlB dlBundleBundle

Not an option, a Necessity

Feeding BundleFeeding Bundle

• What to feedh• When to initiate

– MEN

Wh /H h t d• When/How much to advance• Defining Intolerance

Oth F tifi ti• Other: Fortification, Probiotics, Umbilical lines, PDA Remove CL/Stop PNPDA, Remove CL/Stop PN, Transfusions

What to FeedWhat to Feed

HumanHuman milk for Human Babies!Babies!

Feed InitiationFeed InitiationEarly trophic (<4 days) vs. NPO (4-7 days) Meta-analysis 9 RCT’s: 4 included growth

No difference NECMorgan, et al (2014)

grestrictedDelayed start (7 days NPO): time to FF, on PN, with CL

No difference NECViswanathan, et al (2015)

Introduction of feeds before day 4

Does not increase risk of NEC SIFT Investigator group (2013)

E l (24 48h ) i iti ti i N i i NECEarly (24-48hr) initiation in Growth restricted

No increase in NEC Leaf, et al (2012)

Trophic feedsMeta analysis 10 trials

No difference on NECTyson & Kennedy (2009)Meta-analysis 10 trials Tyson & Kennedy (2009)

Harm in NPOHarm in NPO• Animal/Adult studies

– Mucosal atrophy– Decrease in trophic hormones– Increase in sepsis– Increase risk for systemic inflammatory response syndrome

K d k (2002) Wildh b t l• Kudsk (2002); Wildhaber, et al (2005)

• Continuous flow of amniotic fluid– Interrupted at birth– Interrupted at birth– Normally a significant growth in length and mucosal surface

area in 3rd trimester– “Feeds” needed to continue that stimulation– “Do we blunt growth and development in NICU by our feed

practices?”• Neu (2007)

Feed AdvancementFeed AdvancementMENMEN

Meta-analysis: early trophic (w/in 96hr) vs. NPO

No affect NECBombell & McGuire (2009)

M t l i 6 t di N ff t NECMeta-analysis 6 studies: MEN

No affect NECTyson & Kennedy (2000)

ADVANCEMENTADVANCEMENT

Meta-analysis 5 RCT’s- slow (<15-20ml/kg/d) vs. Fast (30-35ml/kg/d)

No affect NEC/DeathMorgan, et al, (2013)

(30 35ml/kg/d)

Volume > 24 ml/kg/d-No inc NEC risk The SIFT group, (2013)

Meta-analysis- Rapid vs. Slow advance

No affect NECKennedy & Tyson (2000)

Other things to considerOther things to consider

Fortification When to start?

Probiotics Use? Which one?

UAC’s Feed!

PDA MEN!

Stop PN/Pull CL When?

PRBC’s Continue? Stop? MEN?

Residuals Nml physiology (Neu 2007)Residuals Nml physiology (Neu 2007)Not assoc w/NEC (Chauhan, et al 2008; Ziegler 2011)No check- no inc risk (Torrazza, et al 2015)

Defining OUR IntoleranceDefining OUR Intolerance• No uniform definition exists

– Bowel loops, distension, emesis, p , , ,residuals, color of residuals, abd discoloration, bloody stool

Cli i l i ifi t• Clinical significance not determined

• Do they predict disease or just• Do they predict disease or just iatrogenic effects of care (CPAP) or normal developmentalor normal developmental physiology

• (Jadcheria & Kliegman 2002)

What about growth?What about growth?What about growth?What about growth?Can we grow? Can we grow safely?

Preventing PNGRPreventing PNGR

Practices (FD initiation, duration/volume MEN, time to FF) di tl l t d t i id f PNGR

Stevens, et al (2015)

directly related to incidence of PNGRSFA w/focus on “critical period” transition from PN to full enteral- PNGR

Roggero, et al (2012)Senterre & Rigo(2012) PNGR (2012)Miller, et al (2013)

SFA PNGR; No NEC Hanson, et al (2011)Loys, et al (2013)B tl t l (2013)Butler, et al (2013)Miller, et al (2013)Khanam, et al (2014Graziano, et al (2015)( )

Bringing the Evidence Bringing the Evidence t th B d idt th B d idto the Bedsideto the Bedside

Overcoming Obstacles/Helpful Hints

Quality ImprovementQuality Improvement

Evidence + YOUR Evidence

Build your Bundle/Champion(s)

Evidence + YOUR Evidence

Educate ALL

Build your Bundle/Champion(s)

Evidence + YOUR Evidence

Monitor

Educate ALL

Build your Bundle/Champion(s)

Evidence + YOUR Evidence

Feedback

Monitor

Educate ALL

Build your Bundle/Champion(s)

Evidence + YOUR Evidence

Outcomes/RepeatContinuous Improvement

AssessEvaluate

Feedback

DesignImplement

Monitor

Educate ALL

Build your Bundle/Champion(s)

Evidence+ YOUR Evidence

• SFA=Evidence-based medicine• SFA= Reduction/Elimination NEC• SFA= Better practice/Better

Outcomes• SFA= Improved growth/Reduced

PNGR• Success= Build outside YOUR box,

Ongoing Monitoring & Feedback, “Police” Hold AccountablePolice -Hold Accountable

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