27 minutes of tremendous effort and you made the topic looks easy where it’s not on books … Thanks a lot Could you please make and vid specific for what is the practice you do exactly about feeding again for lowering NEC in your units
Hello! Thanks so much for watching and for taking the time to write to us! We work very hard on getting mother's EBM as early as possible, we use donor EBM, we use probiotics and we have a standardised feeding protocol (usually ~ 3 days trophic feeds the smallest babies, then advance by 20ml/kg/day). the older ones we go faster. We also try to minimise antibiotics usage and completely avoid PPI and H2 blockers. Really- everything we can!!!
Great discussion, insights and practices. Our unit (London, UK) does hourly feeds esp. from extreme premies starting from 0.5 hourly (12 mls/kg/day) depending on mother’s breast milk availability and this usually take days before Mum’s produces their milk. Although I do find (observational evidence only) that 2 hourly is well tolerated than hourly feeds by premies. We also have access to Donor breast milk but given only once Mum is well-informed and gives her consent. We use formula fortifier and not human fortifier (still controversial due to its lead concerns). Thank you for your expertise and teachings, so appreciated in this part of NICU world!
Hello- thanks for the insight. I absolutely love learning about what everyone is doing all over the world. We generally start more prolonged time periods (like 4-6 hours between feeds) and then shorten it- mostly to Q3hr feeds. Thank you so much for subscribing and for giving us your great thoughts.
Thank you both of you for discussing on one of the crucial topic in nicu. I would like to ask a few questions related to it. 1. Can we push back the residual? 2. Can we check for residual if we are feeding via transpyloric? 3. If we are feeding continously,how frequently and when should we check for aspiration? 4. Can we put the baby in prone position when on continous feed? 5.Could you suggest which size syringe should we ideally use to feed? Thank you once again!!
These are such good questions- and honestly- lots of GREY area. So I will give my answers- and maybe Sridhar will have others. 1) Yes- we can - and often should give back residuals if they are being checked. There's lots of good secretions, enzymes and food in there, and often babies have worked hard at breaking it down. Generally if it's a dark green color or bloody I won't give it back! 2) Transpyloric feeds are going into the duodenum so none should be in the stomach. If you check for residuals in the stomach- it should use be stomach secretions (which we want to stay in there!). 3) When you say aspiration- you mean reflux and then to lungs? Hoping that if we're using trans-pyloric feeds, the chance of this goes down significantly. 4) Yes! Can continuous feed in prone position! 5) Not sure about syringe sizes- depends on size of baby and feeds. Hope was helpful??!!!!
My LO born somewhere at 26w 6d could never tolerate Human Milk fortifier; no one wanted to remove it (concern for weight gain) despite an unexplainable very swollen tummy that caused lots of discomfort for weeks - I don’t know what’s the practice around this in different countries. She continued gained weight on plain breastmilk and swollen tummy resolved immediately with removal of HMF. I wonder if there are adverse effects reported with HMF but I could not believe that all the KUBs, tummy swelling, discomfort and not being able to tolerate feeds was due to this.
Another great point- I don't think there's anything we give babies that every single baby tolerates perfectly. It's hard stopping something (that we know is So good for growth- and therefore development) if baby is still growing and thriving (ie sometimes we put up with a swollen belly). Again- as I'm sure you realised in the NICU- a lot of what we do is an art (based on as much science as possible!)
Great question- and that's the thing! A lot of people say we should never check residuals so no amount should stop you!!! (go on other signs- eg emesis/ abdominal distention etc). In one unit I worked- if it was < 1/2 feed: we would continue same feed. If > 1/2 we'd subtract volume from what we were giving, and if > full volume, we'd miss a feed. Nobody knows what we really should be doing though!!!!
It would be great if everyone was on board with breastmilk initiation. While I knew I wanted to breastfeed, I wish certain information had been made available to me by the lactation nurses. I think it took longer for my milk to come in because of the shock and confusion I was in. So discussion with the mother before delivery would be helpful - I was in the hospital for days before I had my LO - would have been a great opportunity to discuss. Also if this can really start in the OB side in the first trimester outpatient- it would be helpful. I hope to become a lactation consultant to help mothers esp. those who had babies prematurely. I think breastmilk contributed to the good outcomes she had. And I know some would argue that n = 1 but it’s the easiest thing for her to digest compared to formula.
You've hit the nail on the head here. (In fact would you have any interest in filming a video from parents' side?? What I wish I knew before I had a premature infant??). IT is SO critical to discuss breast feeding as soon as possible with mothers. And getting them to pump as soon after birth as possible is also so important (at getting any BM in but also on how much they produce going forward). I think we all struggle with adding even more pressure to mothers who are already struggling- but obviously this is not for the greater good.
Thanks Tala and Sridhar . Brilliant and very informative as usual . A question if I may. How do you manage Azotaemia post fortification. Do you fortify alternate feeds till the kidneys are able to cope with the protein load. In the our unit we are fortifying when the baby is about 80mls/kg. Another interesting comment about starting babies above 28 weeks on full feeds in India. Could you kindly point me to that paper. Many thanks again
Hello! This is such a great question- and in the tiny ones we deal with this. Its one thing if BUN going up a bit- but if Cr going up too- then we may slow down with fortification. These tiny ones have such sensitive kidneys- so well push slower. Thats our protocol- obviously many units will do different things!
That was a brilliant discussion by stalwarts of neonatology... Immensely informative... Thanks loads for your efforts!
Thank you so much for your lovely comment!!! We really enjoyed chatting!!!
27 minutes of tremendous effort and you made the topic looks easy where it’s not on books …
Thanks a lot
Could you please make and vid specific for what is the practice you do exactly about feeding again for lowering NEC in your units
Hello! Thanks so much for watching and for taking the time to write to us! We work very hard on getting mother's EBM as early as possible, we use donor EBM, we use probiotics and we have a standardised feeding protocol (usually ~ 3 days trophic feeds the smallest babies, then advance by 20ml/kg/day). the older ones we go faster. We also try to minimise antibiotics usage and completely avoid PPI and H2 blockers. Really- everything we can!!!
Good section tx u so mch
Thank you so much for watching and for taking the time to comment!
I clicked the like button before watching. :)) Thank you both!
Ha! Love your support! thanks!!!!
Great discussion, insights and practices. Our unit (London, UK) does hourly feeds esp. from extreme premies starting from 0.5 hourly (12 mls/kg/day) depending on mother’s breast milk availability and this usually take days before Mum’s produces their milk. Although I do find (observational evidence only) that 2 hourly is well tolerated than hourly feeds by premies. We also have access to Donor breast milk but given only once Mum is well-informed and gives her consent. We use formula fortifier and not human fortifier (still controversial due to its lead concerns).
Thank you for your expertise and teachings, so appreciated in this part of NICU world!
Hello- thanks for the insight. I absolutely love learning about what everyone is doing all over the world. We generally start more prolonged time periods (like 4-6 hours between feeds) and then shorten it- mostly to Q3hr feeds. Thank you so much for subscribing and for giving us your great thoughts.
Thank you both of you for discussing on one of the crucial topic in nicu. I would like to ask a few questions related to it.
1. Can we push back the residual?
2. Can we check for residual if we are feeding via transpyloric?
3. If we are feeding continously,how frequently and when should we check for aspiration?
4. Can we put the baby in prone position when on continous feed?
5.Could you suggest which size syringe should we ideally use to feed?
Thank you once again!!
These are such good questions- and honestly- lots of GREY area. So I will give my answers- and maybe Sridhar will have others.
1) Yes- we can - and often should give back residuals if they are being checked. There's lots of good secretions, enzymes and food in there, and often babies have worked hard at breaking it down. Generally if it's a dark green color or bloody I won't give it back!
2) Transpyloric feeds are going into the duodenum so none should be in the stomach. If you check for residuals in the stomach- it should use be stomach secretions (which we want to stay in there!).
3) When you say aspiration- you mean reflux and then to lungs? Hoping that if we're using trans-pyloric feeds, the chance of this goes down significantly.
4) Yes! Can continuous feed in prone position!
5) Not sure about syringe sizes- depends on size of baby and feeds.
Hope was helpful??!!!!
@@TalaTalksNICU thank you so much for your quick response.
@@tenjutenju7935fully agree with above
Our policy is check residual one time per shift . It used to be with each feed
My LO born somewhere at 26w 6d could never tolerate Human Milk fortifier; no one wanted to remove it (concern for weight gain) despite an unexplainable very swollen tummy that caused lots of discomfort for weeks - I don’t know what’s the practice around this in different countries. She continued gained weight on plain breastmilk and swollen tummy resolved immediately with removal of HMF. I wonder if there are adverse effects reported with HMF but I could not believe that all the KUBs, tummy swelling, discomfort and not being able to tolerate feeds was due to this.
Another great point- I don't think there's anything we give babies that every single baby tolerates perfectly. It's hard stopping something (that we know is So good for growth- and therefore development) if baby is still growing and thriving (ie sometimes we put up with a swollen belly). Again- as I'm sure you realised in the NICU- a lot of what we do is an art (based on as much science as possible!)
Thanks for your educative discussion. My question what percentage of residuals would lead to interruption of feeding
Great question- and that's the thing! A lot of people say we should never check residuals so no amount should stop you!!! (go on other signs- eg emesis/ abdominal distention etc). In one unit I worked- if it was < 1/2 feed: we would continue same feed. If > 1/2 we'd subtract volume from what we were giving, and if > full volume, we'd miss a feed.
Nobody knows what we really should be doing though!!!!
It would be great if everyone was on board with breastmilk initiation. While I knew I wanted to breastfeed, I wish certain information had been made available to me by the lactation nurses. I think it took longer for my milk to come in because of the shock and confusion I was in. So discussion with the mother before delivery would be helpful - I was in the hospital for days before I had my LO - would have been a great opportunity to discuss. Also if this can really start in the OB side in the first trimester outpatient- it would be helpful. I hope to become a lactation consultant to help mothers esp. those who had babies prematurely. I think breastmilk contributed to the good outcomes she had. And I know some would argue that n = 1 but it’s the easiest thing for her to digest compared to formula.
You've hit the nail on the head here. (In fact would you have any interest in filming a video from parents' side?? What I wish I knew before I had a premature infant??). IT is SO critical to discuss breast feeding as soon as possible with mothers. And getting them to pump as soon after birth as possible is also so important (at getting any BM in but also on how much they produce going forward). I think we all struggle with adding even more pressure to mothers who are already struggling- but obviously this is not for the greater good.
Thanks Tala and Sridhar . Brilliant and very informative as usual . A question if I may. How do you manage Azotaemia post fortification. Do you fortify alternate feeds till the kidneys are able to cope with the protein load. In the our unit we are fortifying when the baby is about 80mls/kg. Another interesting comment about starting babies above 28 weeks on full feeds in India. Could you kindly point me to that paper. Many thanks again
Prof Ziegler showed the azotemia doesn’t matter (with TPN or with feeds). The article is by Prof Nangia 2019, try searching her name and preterm feeds
Prof Ziegler showed the azotemia doesn’t matter (with TPN or with feeds). The article is by Prof Nangia 2019, try searching her name and preterm feeds
Hello! This is such a great question- and in the tiny ones we deal with this. Its one thing if BUN going up a bit- but if Cr going up too- then we may slow down with fortification. These tiny ones have such sensitive kidneys- so well push slower. Thats our protocol- obviously many units will do different things!