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

2. 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

3. 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

4. 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

5. 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:
Woods, CW, Oliver T, Lewis K, Yang Q. Development of necrotizing entercolitis in premature infants receiving thickened feeds using Simply Thick®

6. 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”

7. 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, cc/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

8. 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.