Thickened Feedings for Premature Infants in the NICU Erin Pryor, MPH, RD, LD April 12, 2012 ONN Spring Meeting Columbus, Ohio

History of Thickening Feeds1 Thickening of infant formulas for treatment of GER for > 50 years - cereal, rice, bean gum, pectin, cellulose Rationale: Thickening increases the stickiness and weight of the feeds - Controversial with evidence of delayed gastric emptying Alternative treatment modalities Prone position with head at 30 degrees Smaller frequent feedings Histamine H-2 antagonists/Proton pump inhibitors Time Severe cases: surgery 1. Reviewers: Huang R-C, Forbes DA, Davies MW http://www.nichd.nih.gov/chochrane/Huang/Huang.htm

Thickening Feeds Common practice yet no evidence of effectiveness - Lack of randomized, controlled studies of non- pharmacological management of GER Spontaneous resolution occurs more frequently in premature neonates Theoretical disadvantages Delayed gastric emptying Increased caloric density Constipation

Diagnostic Tests2 pH probe test Barium swallow study Upper GI Radionuclide milk scans to detect pulmonary aspiration 2. Feed thickener for newborn infants with gastro-oesophageal reflux (Review) The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 2009.

Simply Thick® Xanthan gum-based thickener used in the management of dysphagia Water holding capacity of a non-starch polysaccharide that acts as a soluble food fiber3 Speculation from case review: - Stimulation of an immature gut by xanthan gum4 Sharp K, Ward L, Cichero J, Sopade P, Halley P. Thickened fluids and water absorption in rats and humans. Dysphagia 2007; 22: 193-203. Woods, CW, Oliver T, Lewis K, Yang Q. Development of necrotizing entercolitis in premature infants receiving thickened feeds using Simply Thick®

Case Study Male Premature Infant: 30+6 wks, 1500 gms @ birth DOL 1: TPN DOL 2: Feeds started of 20 kcal/oz EBM/SC per feeding protocol DOL 6: Increased to 24kcal/oz EBM/SC DOL 7: Vits added DOL 10: Full feeds ~150cc/kg DOL 15: Out of EBM DOL 46: Neosure 22kcal/oz, tolerating formula well DOL 52: Noted “Mom feeding well, plan for DC tomorrow”

Case Study DOL 52 Evening: Event needing mod stim w/feeds, dusky in color DOL 55: Event needing vigorous stim x 2 w/ feeds DOL 56: Event needing vigorous stim x 1 w/ feeds DOL 57: 39+2 wks Swallow Study w/ UGI (See OT note) Wt. 3190, 550-680cc/day Initial Recipe: 80 ml Neosure 22kcal 10 ml sterile water ~27 kcal/oz 4.5 tsp Rice cereal MD documented much improved with thickened feeds DOL 60: RN reported difficulty w/ Dr. Browns nipple, taking less volumes and >25 minutes to feed

Case Study DOL 60: Tried yellow nipple with some reported improvement DOL 61: Yellow nipple clogging. Tried Avent Bottle 1 & 2 Flow New Recipe: 80 ml Neosure 22kcal 10 ml sterile water ~26kcal/oz 3.75 tsp rice cereal DOL 62: New Recipe 10 ml sterile water ~25kcal/oz 3 tsp Rice cereal DOL 67: 40+5 wks Only 1 documented event with sleeping (self stim) in the last 5 days since thickened feeds. Infant discharged. Formula mixing done with mom. Follow up with high risk nutrition clinic and GI.