Enteral nutrition: how to support growth and development of preterm and ill newborns safely

Interview with Dr Corinna Gebauer, University Hospital Leipzig, Germany

Photo: © Dr Corinna Gebauer, University Hospital Leipzig, Germany

If a preterm baby or a hospitalized newborn cannot be fed normally, because they are not yet able to coordinate sucking and swallowing, for instance, then enteral feeding can be a way of nutritional support. In this interview, Dr Corinna Gebauer, from the University Hospital Leipzig, Germany, shares her expertise about nutritional support for newborns and the aspect of patient safety regarding enteral feeding of preterm babies.

Question: Could you please explain to us what enteral feeding is and how you practice it in your NICUs?

Dr Corinna Gebauer: Enteral feeding is the optimal route to apply nutrients and fluid to all humans and especially to premature infants. Optimal nutrition is important for normal growth and development. For enteral feeding, the first choice is mother’s own milk. If mother’s own milk is not available the first alternative is donor milk and the third best option – if there is no donor milk bank – is preterm formula. Mothers of preterm babies express their milk – usually with the help of an electric milk pump – and bring their milk cooled or frozen to the NICU where the milk is used immediately or stored in the milk bank. According to the gestational age and individual skills of the baby the milk is given via feeding tubes, bottles, finger feeding or directly from the breast.

Could you explain how important it is for the improvement of the neonatal patient’s health?

Optimal nutrition for newborn infants and preterm infants is mother’s own milk. Human milk is not only nutrition, it consists of much more:  factors that stimulate the development of mucosal epithelium, the intestinal immune system, and the gut motility. It delivers gastrointestinal enzymes, that improve digestion; it delivers prebiotics (human milk oligosaccharides preventing harmful bacteria to invade epithelium) and probiotic bacteria; it contains antimicrobial factors, living cells and hormones to support growth, brain development or regulation of appetite. Adequate nutrition in infancy and especially in preterm infants is essential for long term health in terms of neurocognitive development, growth within a normal body composition and programming of cardiovascular or immunological long-term health.

What are the challenges regarding enteral feeding for preterm infants?

Oral feeding is the preferred method in neonatal feeding. Premature infants are usually placed on a combination of parenteral nutrition (that means nutrition via venous lines) and enteral nutrition in the first few days after birth.

Early minimal enteral feeding with small volumes even in very low birth weight infants is essential to prime the immature gut. If the infants tolerate the feeds volumes are increased. The immature suck and swallow as well as breathing mechanism in preterm infants delays the ability to feed the infants by mouth safely until a certain postnatal gestational age has been reached. Therefore the need for feeding via enteral tubes for a certain time is necessary.

From the point of view of patient safety, could you outline what has to be considered for safe enteral feeding of preterm and ill newborn babies in the NICU?

Tube feeding is the preferred route in enteral nutrition to feed premature infants or ill neonates that are not able to coordinate sucking, swallowing and breathing. Feeding tubes should be radiopaque and scaled to avoid malposition, secondary displacement and ensure the positioning in the stomach. The material of the tubes has to minimize the risk of intestinal perforation, tube occlusion or nutritional losses due to adhesion on the inner wall. Misconnection of enteral drugs, milk or gases to venous lines could be fatal. Different systems for enteral or parenteral applications which are not interconnectable have to be used.

What system do you use today in your NICU and why?

Today we use the “Nutrisafe2” system from Vygon: feeding tubes and syringes with an incompatibility to devices that are used for intravenous applications because it prevents misconnections, which can cause patient injuries or death.

Do you have specific requirements in terms of enteral drugs dosage accuracy?

We use Nutrisafe 2 syringes that are specific for oral administration and cannot be connected to parenteral lines, and that are unable to be connected to needles. With the Nutrisafe 2 enteral system, drugs can be accurately supplied even in small volumes, adapted to preterm infants. The specific colour of the systems is different from parenteral lines and non-nutritional syringes. Different syringe sizes with an adequate scale are used to apply even small volumes such as 0,1ml. Liquid formulations of medications with concentrations that fit the common dosages are available. Measuring spoons, oral droppers, dosing cups are not routinely used. With oral syringes, greater accuracy is reached.

Do you have specific protocols to administrate those enteral drugs?

There are no specific protocols. However, no intravascular syringe is allowed to be used in enteral administration.

Special thanks to Dr Corinna Gebauer, University Hospital Leipzig, Germany, paediatrician and neonatologist, Head of the Human Milk Bank.