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Editorial
Optimising nutrition during therapeutic hypothermia
  1. Shalini Ojha1,
  2. Jon Dorling2,
  3. Cheryl Battersby3,
  4. Nicholas Longford4,
  5. Chris Gale3
  1. 1 Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK
  2. 2 Division of Neonatal-Perinatal Medicine, Faculty of Medicine, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
  3. 3 Section of Neonatal Medicine, Department of Medicine, Imperial College London, London, UK
  4. 4 Neonatal Data Analysis Unit, Section of Neonatal Medicine, Department of Medicine, Imperial College London, London, UK
  1. Correspondence to Dr Chris Gale, Section of Neonatal Medicine, Department of Medicine, Imperial College London, London SW10 9NH, UK; christopher.gale{at}imperial.ac.uk

https://doi.org/10.1136/archdischild-2018-315393

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    There is little evidence to inform provision of enteral or parenteral nutrition to infants with hypoxic ischaemic encephalopathy (HIE) during and soon after therapeutic hypothermia; as a consequence, clinical practice is both variable and changing. A 2014 UK survey found that 79% (33 of 42) of responding neonatal units routinely withheld enteral nutrition during cooling; 3 years later, a similar survey found that 41% (20 of 49) of responding units reported withholding enteral nutrition.1 The latter study also reports wide variation in how, when and how much to feed, and in the use of parenteral nutrition. Internationally, practice is even more variable: withholding enteral feeds is practised almost universally2 in some countries, while in others, milk feeding during hypothermia is routine.3 Here we discuss the limited evidence available to inform enteral and parenteral nutrition during therapeutic hypothermia.

    Enteral nutrition

    The landmark trials4 that provided evidence for the neurodevelopmental benefits of therapeutic hypothermia withheld milk feeds during hypothermia. It is therefore unsurprising that withholding or delaying enteral feeding is commonplace. A major rationale for this practice is to prevent necrotising enterocolitis (NEC). NEC is well described in term infants with HIE, but is rare: among 11 trials, with a total of 1505 infants, included in the Cochrane review of therapeutic hypothermia only three trials reported data on NEC and only one case was identified (in the hypothermia arm of the TOBY (Whole Body Hypothermia for the Treatment of Perinatal Asphyxial Encephalopathy) trial.4 Although the pathogenesis of NEC is incompletely understood, one putative mechanism links the combination of impaired gastrointestinal blood flow (as seen in infants with HIE) and intraluminal substrate (such as milk) to the proinflammatory cascade that leads to gut necrosis and NEC. As a consequence, ‘prevention of NEC’ is a common reason for withholding …

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