Variabilidad en las prácticas sobre alimentación enteral del prematuro entre hospitales españoles de la red SEN-1500 / Variability in enteral feeding practices of preterm infants among hospitals in the SEN1500 Spanish neonatal network

Introducción: La nutrición adecuada es uno de los objetivos primordiales en el manejo de los recién nacidos prematuros. Sin embargo, la falta de evidencia en cuanto a cuál es la mejor estrategia para alcanzar este objetivo da lugar a que exista una gran variabilidad en las prácticas de alimentación. Esta variabilidad podría estar relacionada con las diferencias que existen en la incidencia de complicaciones como la enterocolitis necrosante (ECN). Objetivo: Valorar la variabilidad en las prácticas sobre alimentación entre las unidades neonatales de la red SEN-1500. Método: Estudio transversal, mediante cuestionario, solicitando información sobre alimentación del recién nacido de muy bajo peso (RNMBP) (leche donada, momento de inicio, trófica, incrementos, fortificantes, probióticos) en el año 2013. Resultados: Contestaron 60/98 hospitales; la tasa de respuesta fue mayor en centros con más de 50 RNMBP/año (30/31). El 67% tienen protocolo de alimentación, el 52% refieren variabilidad en su unidad y el 25% disponen de leche donada. Se inicia la alimentación en las primeras 48 h, aunque se retrasa en las edades más bajas aun en ausencia de fallo hemodinámico. Además de la inestabilidad hemodinámica hay otras situaciones por las que se demora su inicio (ausencia de leche materna, CIR, flujo umbilical alterado, asfixia), mientras que raramente se retrasa por ausencia de meconio o por mantener un catéter umbilical. Por debajo de 25 semanas la mitad comienzan directamente con incrementos progresivos en lugar de nutrición trófica. Los incrementos raramente alcanzan 30 ml/kg/día. Casi todos usan fortificantes y vitaminas. El uso de probióticos es excepcional. Conclusiones: Existe gran variabilidad en la política de alimentación del RNMBP entre las unidades neonatales españolas. Aunque algunas diferencias en las prácticas de alimentación están justificadas por la falta de evidencia, hay intervenciones que sí han demostrado su eficacia, como disponer de un protocolo de alimentación (basado en pruebas) o tener acceso a leche donada; su implementación en todos los centros podría disminuir la incidencia de ECN y mejorar el estado nutricional de los RNMBP (AU)

Introduction: Proper nutrition is one of the primary objectives in the management of preterm infants. However, lack of evidence on the best strategy to achieve this objective has led to a great variability in feeding practices. This variability may be related to the differences in the incidence of complications, such as necrotising enterocolitis (NEC). Objective: The aim of this study is to assess the variability in clinical practice regarding enteral feeding in SEN-1500 Spanish network. Method: An observational study was conducted using a questionnaire sent out in 2013 requesting information about feeding very low birth weight (VLBW) neonates (bank milk, start time, trophic feeding, increases, fortifiers and probiotics). Results: Responses were received from 60 of the 98 hospitals. The response rate was higher in centres with more than 50VLBW/year (30/31). Just over two-thirds (67%) have feeding protocols, and 52% refer to variability within their unit. A milk bank is available in 25% of the units. First feeding occurs fairly evenly throughout first 48hours, although it is delayed in lower gestational ages, even when there is no haemodynamic failure. In addition to hemodynamic instability there are other situations when the start is delayed (absence of breast milk, CIR, altered umbilical flow, asphyxia), while it is rarely delayed by absence of meconium or maintain an umbilical catheter.Half of those under 25 weeks begin directly with progressive increases instead of trophic feeding. Increases rarely reach 30ml/kg/day. Almost all use fortification and vitamins. There was a significant use of probiotics at the time of the survey. Conclusions: There is great variability in enteral nutrition policies in VLBW in Spain. Although some differences are justified by the lack of evidence, there are other interventions that have proven to be effective, such as evidence-based protocols or access to donor milk. Implementation in all the units could reduce the incidence of NEC and improve the nutritional status (AU)

[Variability in enteral feeding practices of preterm infants among hospitals in the SEN1500 Spanish neonatal network]. / Variabilidad en las prácticas sobre alimentación enteral del prematuro entre hospitales españoles de la red SEN-1500.

INTRODUCTION: Proper nutrition is one of the primary objectives in the management of preterm infants. However, lack of evidence on the best strategy to achieve this objective has led to a great variability in feeding practices. This variability may be related to the differences in the incidence of complications, such as necrotising enterocolitis (NEC). OBJECTIVE: The aim of this study is to assess the variability in clinical practice regarding enteral feeding in SEN-1500 Spanish network. METHOD: An observational study was conducted using a questionnaire sent out in 2013 requesting information about feeding very low birth weight (VLBW) neonates (bank milk, start time, trophic feeding, increases, fortifiers and probiotics). RESULTS: Responses were received from 60 of the 98 hospitals. The response rate was higher in centres with more than 50VLBW/year (30/31). Just over two-thirds (67%) have feeding protocols, and 52% refer to variability within their unit. A milk bank is available in 25% of the units. First feeding occurs fairly evenly throughout first 48hours, although it is delayed in lower gestational ages, even when there is no haemodynamic failure. In addition to hemodynamic instability there are other situations when the start is delayed (absence of breast milk, CIR, altered umbilical flow, asphyxia), while it is rarely delayed by absence of meconium or maintain an umbilical catheter.Half of those under 25 weeks begin directly with progressive increases instead of trophic feeding. Increases rarely reach 30ml/kg/day. Almost all use fortification and vitamins. There was a significant use of probiotics at the time of the survey. CONCLUSIONS: There is great variability in enteral nutrition policies in VLBW in Spain. Although some differences are justified by the lack of evidence, there are other interventions that have proven to be effective, such as evidence-based protocols or access to donor milk. Implementation in all the units could reduce the incidence of NEC and improve the nutritional status.

Reducción de la enterocolitis necrosante tras la introducción de un protocolo de alimentación enteral basado en la evidencia en recién nacidos de muy bajo peso / Reduction in necrotising enterocolitis after implementing an evidence-based enteral nutrition protocol in very low birth weight newborns

INTRODUCCIÓN: En nuestro hospital asistimos a un incremento inesperado en la incidencia de enterocolitis necrosante (ECN). Por si nuestra política de alimentación estaba influyendo, se realizó e implementó una guía de práctica clínica (GPC) de alimentación enteral del recién nacido de muy bajo peso al nacimiento (RNMBP). OBJETIVO: Valorar el impacto del nuevo régimen de alimentación en la incidencia de ECN. MÉTODO: Estudio antes (2011) y después (mayo del 2012-abril del 2013) de la introducción del nuevo protocolo de alimentación, que incluye: inicio de la alimentación enteral en ausencia de problema hemodinámico; periodo de nutrición trófica de 5-7 días, incrementos posteriores de 20-30ml/kg/día; leche materna/banco desde el inicio. No se utilizaron probióticos. La variable principal a estudio fue la incidencia de ECN ≥ II de Bell. Variables secundarias: perforación focal, mortalidad global y atribuida a ECN, sepsis nosocomial; peso a los 28 días y 36 semanas; % de RN con peso < p10 al alta; estancia hospitalaria. RESULTADOS: Doscientos setenta RNMBP, 155 antes y 115 después. La ECN descendió significativamente (12/155 vs. 1/115, p = 0,008); la mortalidad se redujo (17,4% vs. 7,8%, p = 0,02); en 4 casos la ECN formó parte de la secuencia que condujo a la muerte en la primera cohorte; ninguno en la segunda. No hubo diferencias en la incidencia de perforación intestinal focal ni en las otras variables secundarias analizadas. CONCLUSIONES: La protocolización del régimen de alimentación enteral con la máxima evidencia disponible produce un descenso en incidencia de ECN sin incrementar la estancia hospitalaria o la incidencia de sepsis

INTRODUCTION: An unexpected increase in the incidence of necrotising enterocolitis (NEC) cases was observed in our hospital. Just in case, our feeding policy could be responsible, it was decided to conduct a systematic review and develop a clinical guideline regarding enteral nutrition of very low birth weight infants (VLBW). OBJECTIVE: To assess the impact of the new feeding protocol in the incidence of NEC. Method. A «before» (2011) and «after» (May 2012 - April 2013) study was performed on the new feeding protocol. This included initiation of enteral feeding in the absence of haemodynamic problems, a trophic feeding period of 5-7 days, and subsequent increments of 20-30ml/kg/day, of breast milk/donor human milk from the beginning. Probiotics were not administered. Primary outcome: incidence of NEC II 2 Bell's stage. Secondary outcomes: focal intestinal perforation, overall mortality and mortality due to NEC, nosocomial sepsis; weight at 28 days and 36 weeks; % of infants with weight Results. Of the 270 VLBW infants, 155 were included in the «before» group, and 115 in the «after» group. NEC significantly decreased (12/155 vs 1/115, P=.008). A decrease in mortality rate was also observed (17.4% vs 7.8%, P=.02). In four cases NEC was part of the sequence of events that led to death in the first cohort, with none in the second. There was no difference in the incidence of focal intestinal perforation or of the other secondary variables analysed. CONCLUSIONS: Implementation of an evidence-based enteral feeding protocol leads to a decrease in incidence of NEC, without increasing hospital stay or the incidence of sepsis

[Reduction in necrotising enterocolitis after implementing an evidence-based enteral nutrition protocol in very low birth weight newborns]. / Reducción de la enterocolitis necrosante tras la introducción de un protocolo de alimentación enteral basado en la evidencia en recién nacidos de muy bajo peso.

INTRODUCTION: An unexpected increase in the incidence of necrotising enterocolitis (NEC) cases was observed in our hospital. Just in case, our feeding policy could be responsible, it was decided to conduct a systematic review and develop a clinical guideline regarding enteral nutrition of very low birth weight infants (VLBW). OBJECTIVE: To assess the impact of the new feeding protocol in the incidence of NEC. METHOD: A "before" (2011) and "after" (May 2012 - April 2013) study was performed on the new feeding protocol. This included initiation of enteral feeding in the absence of haemodynamic problems, a trophic feeding period of 5-7 days, and subsequent increments of 20-30ml/kg/day, of breast milk/donor human milk from the beginning. Probiotics were not administered. PRIMARY OUTCOME: incidence of NEC II 2 Bell's stage. SECONDARY OUTCOMES: focal intestinal perforation, overall mortality and mortality due to NEC, nosocomial sepsis; weight at 28 days and 36 weeks; % of infants with weight