Paediatrica Indonesiana: Teti Hendrayani, Afifa Ramadanti, Indrayady, Raden Muhammad Indra
Paediatrica Indonesiana: Teti Hendrayani, Afifa Ramadanti, Indrayady, Raden Muhammad Indra
Paediatrica Indonesiana: Teti Hendrayani, Afifa Ramadanti, Indrayady, Raden Muhammad Indra
Original Article
L
Abstract ow birth weight (LBW) is defined as birth
Background Early enteral feeding is one of the efforts to improve weight lower than 2,500 grams, and further
gastrointestinal adaptability in preterm infants. Volume advance- classified into very LBW (VLBW), birth weight
ment (VA) enteral feeding has been associated with less time to
reach full feeding, which can improve outcomes. <1,500 grams and extremely (ELBW), birth
Objective To evaluate the duration of VA needed to achieve full weight <1,000 grams. Depending on gestational age,
enteral feeding (FEF) in low birth weight (LBW) and very low infants are grouped as moderate to late preterm, very
birth weight (VLBW) infants and related factors.
Methods This prospective study was done in infants with birth
preterm, and extremely preterm.1,2
weight 1,000 to <2,000 grams in the Neonatal Ward and NICU of More than 20 million infants worldwide repre-
Dr. Moh. Hoesin General Hospital, Palembang, South Sumatera. senting 15.5% of all births are born with low birth
All infants underwent VA feeding. The time needed to achieve weight, 96.5% of them in developing countries.3 In
FEF (150 mL/kg/day) was recorded. Several clinical factors were
analyzed for possible associations with the success rate of achieving 2013, the incidence was 10.2% in Indonesia and 9%
FEF within 10 days of feeding. in South Sumatera.4 According to medical records at
Results Thirty-five infants were included in this study with a mean Dr. Moh. Hoesin General Hospital (RSMH) in 2017,
gestational age of 31.83 (SD 2.67) weeks. Their median body
377 infants hospitalized in the NICU and Neonate
weight at the start of protocol was 1,400 (range 1,000-1,950) grams
and 80% had hyaline membrane disease. Median time to achieve Ward had body weight of 1,000 grams to < 2,000
FEF was 11 (range 8-21) days, with 48.6% subjects achieving FEF grams (data not published).
in ≤10 days. Gestational age <32 weeks (OR 5.404, 95%CI 0.963 Preterm infants have a high risk of mortality due
to 30.341), birth weight <1,500 grams (OR 5.248, 95%CI 0.983
to 28.003), and male gender (OR 4.751, 95%CI 0.854 to 26.437) to their immature organs, including gastrointestinal
were associated with the failure of achieving FEF within 10 days
of feeding, however, no factors remained statistically significant
after multivariate analysis.
Conclusion Full enteral feedings in infants with birth weight From the Department of Child Health, Universitas Sriwijaya Medical
1,000 to <2,000 grams with VA feeding are achieved within School/Dr. Moh. Hoesin General Hospital, Palembang, South Sumatra,
a median of 11 days. Gestational age, birth weight, and gender Indonesia.
are not associated with time needed to achieve FEF. [Paediatr
Indones. 2020;60:173-7 ; DOI: 10.14238/pi60.4.2020.173-7]. Corresponding author: Afifa Ramadanti. Department of Child Health,
Universitas Sriwijaya Medical School/Dr. Moh. Hoesin General Hospital;
Tel. +62-711-354088; Fax 0711-351318; Email address: afifa.ramadanti@
yahoo.com.
Keywords: LBW; VLBW; preterm infants; volume
advancement; full enteral feeding Submitted October 18, 2019. Accepted July 7, 2020.
problems, as well as immature oromotor function, 24-48 hours after birth. Volume was increased
such as the lack of sucking and swallowing reflex gradually with 20 mL/kg/day increments based on
coordination. These problems may cause difficulty clinical condition. Full enteral feeding (FEF) was
in achieving FEF in LBW and VLBW infants, defined as the ability to tolerate 150 mL/kg/day
predisposing them to malnutrition. Two previous of enteral feeding. Feeding consisted of expressed
studies showed that VLBW infants are at risk of breast milk or premature formula by nasogastric tube.
developmental delay, emphasizing the need for long- Before achieving FEF, additional parenteral nutrition
term neurodevelopmental follow-up.1,5,6 was given to meet nutritional requirements. Infants
Enteral feeding for LBW infants typically starts experiencing clinical deterioration that necessitated
at 10-15 mL/kg BW/day, with breast milk or formula cessation of enteral feeding for >24 hours were
for preterm infants. There are two enteral feeding considered to have dropped out. And for unstable
strategies: frequency advancement (FA) and volume infants, who had respiratory distress, hypoglycemia,
advancement (VA). In the VA method, feeding is hypotension and shock, had late enteral feeding.
characterized by rapidly increasing administered We also analyzed factors that may affect the time
volume in increments of 20 mL/kg BW/day, while in needed to achieve FEF, including gestational age, weight
the FA method, the frequency of administration is at the start of enteral feeding, presence of infection
increased before volume. The goal of enteral feeding (clinical sepsis, sepsis, or bronchopneumonia), and
is to achieve full enteral feeding (FEF) of 150 mL/kg respiratory distress syndrome.9,11 Clinical sepsis was
BW/day.7-10 Early achievement of FEF (within 10 days) defined as general signs or symptoms of weakness,
is associated with fewer nutritional complications.11 feeding problems, weight loss, lethargy, apnea attacks,
Several factors may influence the achievement of FEF dyspnea, cyanosis, diarrhea, vomiting, or circulatory
in LBW and VLBW infants, including gestational age, or hematological disorders. Sepsis was defined as
birth weight, APGAR score at 5 minutes, weight at signs and symptoms of clinical sepsis with two or
feeding initiation, type of milk, and infection.11 more laboratory findings: leukocyte < 5,000/mm3 or
This study was done in LBW and VLBW infants > 34,000/mm3, ratio of immature to total neutrophils
with weights of 1,000 grams to < 2,000 grams, as a of 0.2 or more, ESR > 15 mm/hours, and C-reactive
pilot study, to identify the time required to achieve protein > 9 mg/dL. Bronchopneumonia was defined
FEF (150 mL/kgBW/day) using VA enteral feeding. as breathing difficulties characterized by dyspnea,
We also evaluated other factors potentially affecting tachypnea, chest retractions, respiratory grunting,
FEF time. cyanosis with normal or decreased respiratory sounds,
crackles, rales, and infiltrates on chest x-ray.2
This study was reviewed and approved by the
Methods Ethics Committee of Sriwijaya University Medical
Faculty. Bivariate analysis was done using Chi-square
This prospective study was conducted from October test and multivariate analysis using logistic regression
2018 to February 2019 in Neonatal Ward and test. Statistical analyses were carried out using SPSS
NICU of Mohammad Hoesin Hospital (RSMH), for Windows version 24.0.
Palembang, South Sumatera. Hospitalized infants
with birth weight 1,000 to < 2,000 grams were
screened for inclusion after parents provided written, Results
informed consent. Infants with major congenital
malformations, malformation of the gastrointestinal Forty-two infants were screened for our study, but seven
tract, intraventricular hemorrhage grades 3 and 4, dropped out from study because of clinical deterioration
hypoxic ischemic encephalopathy, or incomplete [NEC (2 infants), respiratory failure due to pulmonary
infant data (no APGAR score, no birth data, such as hemorrhage and subsequent death (2) duodenal
birth weight) were excluded from this study. stenosis (1), and gastrointestinal bleeding leading to
All stable infants were enrolled and given cessation of enteral nutrition more than 24 hours (2)].
10 mL/kg/day in three hourly enteral feedings within Hence, a total of 35 infants were analyzed (Table 1).
Table 2. Bivariate analysis of factors potentially affecting achievement of FEF within 10 days enteral feeding (N=35)
Variables Not achieved Achieved Total RR 95%CI P value
Gestational age
< 32 weeks 11 4 15 2.095 0.167 to 1.008 0.025
32 or more weeks 7 13 20
Body weight at start of protocol
1,000 to < 1,500 grams 14 7 21 2.33 0.234 to 0.930 0.027
1,500 to < 2,000 grams 4 10 14
Gender
Male 12 7 19 1.684 0.293 to 1.188 0.130
Female 6 10 16
Type of milk
Formula milk 10 11 21 0.952 0.478 to 1.898 0.890
Breast milk 7 7 14
Infection
Yes 4 3 7 1.143 0.545 to 2.397 0.735
No 14 14 28
Clinical sepsis
Yes 2 1 3 0.627 0.123 to 3.212 0.478*
No 15 17 32
Sepsis
Yes 0 3 3 2.133 1.475 to 3.085 0.125*
No 15 17 32
Bronchopneumonia
Yes 2 1 3 0.427 0.047 to 4.744 0.478*
No 17 15 32
HMD
Yes 17 14 31 2.194 0.390 to 12.338 0.261*
No 1 3 4
*Fisher’s exact test
Table 3. Correlation with weight gain per day Table 4. Regression logistic analysis for factors potentially affecting
achievement of FEF within initial 10 days of enteral feeding
Variables r P value
Variables OR 95%CI P value
Body weight at start of protocol -0.531 0.001
Gestational age < 32 weeks 5.404 0.963 to 30.341 0.055
Gestational age -0.317 0.063
BW < 1,500 grams 5.248 0.983 to 28.003 0.052
Gender 4.751 0.854 to 26.437 0.075
scores, maternal hypertension, Caesarean delivery,
formula milk, presence of patent ductus arteriosus,
and complicating illnesses such as respiratory distress more than 10 days. We recommend a larger study to
syndrome, sepsis, and pneumonia.11 The lack of better characterize factors affecting the success of
association in our study may have been due to the achieving FEF using VA enteral feeding.
small sample size. Moreover, the majority of subjects
in our study had respiratory distress syndrome, which
may mask its effects and the effects of other illnesses. Conflict of interest
In conclusion, infants with weight 1,000 to < 2,000
grams who receive volume advancement enteral None declared.
feeding, have a median duration of 11 days to achieve
FEF, which is slightly longer than the recommended Funding Acknowledgment
duration of 10 days. We also noted VA enteral feeding
to be safe. Infants with younger gestational age, lower The authors received no specific grants from any funding agency
starting weight, and male sex tend to achieve FEF in in the public, commercial, or not-for-profit sectors.