A Strategy to Reduce Critical Cardiorespiratory Alarms due to Intermittent Enteral Feeding of Preterm Neonates in Intensive Care

Rohan Joshi, Carola van Pul, Anouk Sanders, Hans Weda, Jan Willem Bikker, Loe Feijs, Peter Andriessen, Rohan Joshi, Carola van Pul, Anouk Sanders, Hans Weda, Jan Willem Bikker, Loe Feijs, Peter Andriessen

Abstract

Background: Many preterm infants require enteral feeding as they cannot coordinate sucking, swallowing, and breathing. In enteral feeding, milk feeds are delivered through a small feeding tube passed via the nose or mouth into the stomach. Intermittent milk feeds may either be administered using a syringe to gently push milk into the infant's stomach (push feed) or milk can be poured into a syringe attached to the tube and allowed to drip in by gravity (gravity feed). This practice of enteral feeding is common in neonatal intensive care units. There is, however, no evidence in the literature to recommend the use of one method of feeding over the other.

Objective: The aim of this study was to investigate which of the two methods of feeding is physiologically better tolerated by infants, as measured by the incidence of critical cardiorespiratory alarms during and immediately after feeding.

Methods: We conducted a prospectively designed observational study with records of all feeding episodes in infants of gestational age less than 30 weeks at birth and with a minimum enteral intake of 100 mL/kg/day. In total, 2140 enteral feeding episodes were noted from 25 infants over 308 infant-days with records for several characteristics of the infants (eg, gestational age), feeding (eg, the position of infants), and of nursing-care events before feeding (eg, diapering). Logistic regression with mixed effects was used to model cardiorespiratory alarms for the push and gravity methods of feeding.

Results: After adjustments were made for all confounding variables, the position of infants was found to be statistically significant in changing the outcome of critical alarms for the two methods of feeding (P=.02). For infants in the lateral position, push feeds led to 40% more instances of one or more critical cardiorespiratory alarms in comparison with the gravity method. Both methods of feeding created a statistically comparable number of alarms for infants in the prone position.

Conclusions: This study provides objective data that may assist in optimizing enteral feeding protocols for premature infants. The incidence of critical cardiorespiratory alarms for infants in the lateral position can be lowered by the use of gravity instead of push feeding. No differences were observed between the two types of feeding when infants were in the prone position.

Keywords: alarms; bradycardia; enteral feeding; hypoxia; preterm infants.

Conflict of interest statement

Conflicts of Interest: No financial assistance was received in support of this study. Jan-Willem Bikker, an employee of Consultants in Quantitative Methods BV, consulted for Philips Research for this study. The remaining authors report no conflict of interest.

©Rohan Joshi, Carola van Pul, Anouk Sanders, Hans Weda, Jan Willem Bikker, Loe Feijs, Peter Andriessen. Originally published in the Interactive Journal of Medical Research (http://www.i-jmr.org/), 20.10.2017.

Figures

Figure 1
Figure 1
Each feeding episode is of variable duration with A and B representing the start and end time of feeding, respectively. Nursing care takes place in the period immediately before feeding. Alarms are analyzed for periods of prefeeding, during feeding, and postfeeding.
Figure 2
Figure 2
The average number of all desaturations and bradycardia alarms measured during the study period is plotted through the 24 hours of the day. The 2-hourly increase in alarms (at even hours) occurs at times scheduled for nursing care and enteral feeding. The resolution of the x-axis is 10 min. The y-axis represents the alarm rate for 100 patients per 10 min.
Figure 3
Figure 3
The probability of alarms in the prone (blue line) and lateral (red line) position for push and gravity types of feeding during and immediately after feeding. The intersection of the lines indicates an interaction between the position of the infant and the type of feeding. In the lateral position, the push method of feeding leads to a 40% increase in the probability of alarms in comparison with gravity (P=.02). The type of feeding does not affect the number of alarms when prone. The error bars indicate the standard deviation of the probability estimates.

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