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• Response: High flow nasal cannula versus NCPAP: No difference in time to full oral feeds
  Jan Miletin
  Published on: 12 October 2017
• High flow nasal cannula versus NCPAP: No difference in time to full oral feeds
  Jogender Kumar
  Published on: 17 August 2017

• Published on: 12 October 2017

  Response: High flow nasal cannula versus NCPAP: No difference in time to full oral feeds

  • Jan Miletin, UCD Clinical Professor, Consultant Neonatologist Coombe Women and Infants University Hospital

  We are delighted that our work received the attention of the neonatal community. The protocol in the study was exactly as stated in our paper, oral feeds were offered at least once in 72 hours, more often if cues were evident. As cue-based feeding depends on individual infants’ physiological wellbeing and readiness to feed a traditional feeding guideline based on volume and time would be contradictory. The cue based feeding might have some effect on earlier achievement of the full oral feeding.(1) Usual total feeding volume in our unit is between 120 ml/kg/day to 180 ml/kg/day and this depends on several factors: co-morbidity (e.g. patent ductus arteriosus, chronic lung disease), type of milk (maternal breast milk, donor breast milk, different type of formulas), weight gain. The total enteral intake would not be feasible to protocolize. The volume taken orally (volume per feed and hike of feeds) was determined by the effort and energy of each individual baby as opposed to following any particular schedule (as mentioned earlier cue-based or infant-led feeding). As our cohort consisted of infants on full enteral feeding, there was no specific definition of feeding intolerance and indeed we did not identify any problems with feeding intolerance in the trial.
  The first oral feed in our trial was 9.3 ± 6.5 days after randomization in High Flow (HF) group and 10.9 ± 4.8 days in nasal Continuous Positive Airway Pressure (CPAP) group, that is 33.3 ± 0.9 weeks of postmenstru...

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  We are delighted that our work received the attention of the neonatal community. The protocol in the study was exactly as stated in our paper, oral feeds were offered at least once in 72 hours, more often if cues were evident. As cue-based feeding depends on individual infants’ physiological wellbeing and readiness to feed a traditional feeding guideline based on volume and time would be contradictory. The cue based feeding might have some effect on earlier achievement of the full oral feeding.(1) Usual total feeding volume in our unit is between 120 ml/kg/day to 180 ml/kg/day and this depends on several factors: co-morbidity (e.g. patent ductus arteriosus, chronic lung disease), type of milk (maternal breast milk, donor breast milk, different type of formulas), weight gain. The total enteral intake would not be feasible to protocolize. The volume taken orally (volume per feed and hike of feeds) was determined by the effort and energy of each individual baby as opposed to following any particular schedule (as mentioned earlier cue-based or infant-led feeding). As our cohort consisted of infants on full enteral feeding, there was no specific definition of feeding intolerance and indeed we did not identify any problems with feeding intolerance in the trial.
  The first oral feed in our trial was 9.3 ± 6.5 days after randomization in High Flow (HF) group and 10.9 ± 4.8 days in nasal Continuous Positive Airway Pressure (CPAP) group, that is 33.3 ± 0.9 weeks of postmenstrual age and 33.6 ± 0.7 weeks respectively. This would be in keeping with premature newborn physiology, when efficient coordination of suck, swallow and breathing occurring between 32 and 36 weeks of gestation.(2, 3) In fact this result compares favorably to previous reports. Hwang et al. in their cohort of infants born below 32 weeks of gestation reported first oral feed at 33.9 ± 1.7 weeks of postmenstrual age. Their group included all infants born below 32 weeks who achieved full oral feeding before discharge.(4) The infants included in our cohort were more premature (born below 30 weeks of gestation). We also excluded the ‘healthiest’ infants who were off respiratory support (63 in total, which would be over 40% of eligible infants). On the other hand we excluded also the ‘sickest’ infants with high respiratory support (19 infants) and infants who were not established on full enteral feeds at 32 weeks of gestation (5 infants). Shetty et al. in their cohort of infants similar in profile to our population reported first oral feed at median of 35 weeks of postmenstrual age (range 33 to 44 weeks) in CPAP group and 34.4 (range 33 to 37.86) in HF/CPAP group.(3) A physiological study undertaken by Amaizu et al. showed ability of infants born between 26 and 29 weeks of gestation to tolerate 1 to 2 oral feeds in 24 hours at 34.0 ± 1.0 weeks of postmenstrual age, this ability improved with gestational age at birth (34.4 ± 1.2 weeks at 26 to 27 weeks of gestation versus 33.6 ± 0.6 weeks at 28 to 29 weeks of gestation). It is worth noting that these were stable infants without chronic lung disease.(5) We would therefore believe that our results fully reflect the physiology of oral feeding in preterm newborns and would be fully justifiable for clinical practice.
  We are using non-nutritive sucking in our unit as a standard practice.
  We would like to thank you for the correction of our terminology used in reference to the important work of Shetty et al., however we believe that their work was a retrospective cohort study (retrospectively comparing two cohorts of infants managed differently in different time epochs).(3)
  We firmly believe that our conclusion was justified that there was no difference in the duration to reach full oral feeds between stable preterm infants managed on HF Nasal Cannula and those managed on nasal CPAP, and that oral feeding was feasible and safe regardless of the method used for non-invasive respiratory support.(6)

  1. Watson J, McGuire W. Responsive versus scheduled feeding for preterm infants. Cochrane database of systematic reviews (Online). 2016(8):CD005255. Epub 2016/09/01.
  2. Foster JP, Psaila K, Patterson T. Non-nutritive sucking for increasing physiologic stability and nutrition in preterm infants. Cochrane database of systematic reviews (Online). 2016;10:CD001071. Epub 2016/11/02.
  3. Shetty S, Hunt K, Douthwaite A, Athanasiou M, Hickey A, Greenough A. High-flow nasal cannula oxygen and nasal continuous positive airway pressure and full oral feeding in infants with bronchopulmonary dysplasia. Archives of disease in childhood Fetal and neonatal edition. 2016;101(5):F408-11. Epub 2016/02/18.
  4. Hwang YS, Ma MC, Tseng YM, Tsai WH. Associations among perinatal factors and age of achievement of full oral feeding in very preterm infants. Pediatrics and neonatology. 2013;54(5):309-14. Epub 2013/05/11.
  5. Amaizu N, Shulman R, Schanler R, Lau C. Maturation of oral feeding skills in preterm infants. Acta paediatrica. 2008;97(1):61-7. Epub 2007/12/07.
  6. Glackin SJ, O'Sullivan A, George S, Semberova J, Miletin J. High flow nasal cannula versus NCPAP, duration to full oral feeds in preterm infants: a randomised controlled trial. Archives of disease in childhood Fetal and neonatal edition. 2017;102(4):F329-F32. Epub 2016/12/25.

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  Conflict of Interest:
  None declared.

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• Published on: 17 August 2017

  High flow nasal cannula versus NCPAP: No difference in time to full oral feeds

  • Jogender Kumar, Neonatologist Post Graduate Institute of Medical education and Research, Chandigarh India 160012

  We read with great interest the article by Sinead J Glackin et al, published in this journal and found the results impressive.[1]. However, we have certain observations about the conduct of the study.
  Even though it was a randomized controlled trial and authors mentioned that oral feeds were offered in both groups at least once every 72 hours and additional feeds were offered when neonates demonstrated feeding cues but they didn’t mention about the exact feeding schedule like frequency of oral feeding, volume per feed and rate of hike of feeds in each group. This bears an important implication on the primary outcome as well as the external validity of the study. If there is no well-defined policy then there will be individualization of practice and lot of bias in the study despite randomization. It’s also worth emphasizing here that the authors should have mentioned about the local guidelines practiced for feed hiking and definition of feed intolerance, for the sake of external validity.
  Despite being eligible and in a trial authors could give first oral feed 9-10 days after the enrollment. The reason for the delay of initiation of oral feeds for so many days despite eligibility is not very clear. Even in a randomized trail when we fail to initiate oral feeds before 33-34 weeks of corrected gestational age, it will not be feasible in routine practice. So, before using these results in clinical practice we should have strong evidence for the age of initiation of...

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  We read with great interest the article by Sinead J Glackin et al, published in this journal and found the results impressive.[1]. However, we have certain observations about the conduct of the study.
  Even though it was a randomized controlled trial and authors mentioned that oral feeds were offered in both groups at least once every 72 hours and additional feeds were offered when neonates demonstrated feeding cues but they didn’t mention about the exact feeding schedule like frequency of oral feeding, volume per feed and rate of hike of feeds in each group. This bears an important implication on the primary outcome as well as the external validity of the study. If there is no well-defined policy then there will be individualization of practice and lot of bias in the study despite randomization. It’s also worth emphasizing here that the authors should have mentioned about the local guidelines practiced for feed hiking and definition of feed intolerance, for the sake of external validity.
  Despite being eligible and in a trial authors could give first oral feed 9-10 days after the enrollment. The reason for the delay of initiation of oral feeds for so many days despite eligibility is not very clear. Even in a randomized trail when we fail to initiate oral feeds before 33-34 weeks of corrected gestational age, it will not be feasible in routine practice. So, before using these results in clinical practice we should have strong evidence for the age of initiation of feeds. Most of the units practice cue based feeding initiation and hiking. There is enough evidence to suggest that non-nutritive sucking reduces the time infants need to transition from tube to full oral feeding,[2] here it is worth to mention about this practice in the study population.
  A prospective cohort study by Shetty et al,[3] is inappropriately mentioned as case series at multiple places in the article.
  Overall this trial succeeds in giving a clear message on feasibility and safety of oral feeding while on nasal CPAP or high flow nasal cannula.

  Competing interests: None
  Source of funding: None

  References:
  1. Glackin SJ, O’Sullivan A, George S, et al. High flow nasal cannula versus NCPAP, duration to full oral feeds in preterm infants: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed. 2017;102:F329–32.
  2. Foster JP, Psaila K, Patterson T. Non-nutritive sucking for increasing physiologic stability and nutrition in preterm infants. Cochrane Database Syst Rev. 2016 Oct 4;10:CD001071.
  3. Shetty S, Hunt K, Douthwaite A, et al. High-flow nasal cannula oxygen and nasal continuous positive airway pressure and full oral feeding in infants with bronchopulmonary dysplasia. Arch Dis Child Fetal Neonatal Ed. 2016;101:F408-411.

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  Conflict of Interest:
  None declared.

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