Thickened Feedings for
Premature Infants
in the NICU
Erin Pryor, MPH, RD, LD
April 12, 2012
ONN Spring Meeting
Columbus, Ohio
History of Thickening
1
Feeds
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Thickening of infant formulas for treatment of GER
for > 50 years
- cereal, rice, bean gum, pectin, cellulose
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Rationale: Thickening increases the stickiness and
weight of the feeds
- Controversial with evidence of delayed gastric
emptying
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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
http://www.nichd.nih.gov/chochrane/Huang/Huang.htm
Thickening Feeds
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Common practice yet no evidence of
effectiveness
- Lack of randomized, controlled studies of nonpharmacological management of GER
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Spontaneous resolution occurs more
frequently in premature neonates
Theoretical disadvantages
- Delayed gastric emptying
- Increased caloric density
- Constipation
Diagnostic Tests2
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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. 2009.
Simply Thick®
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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
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Speculation from case review:
- Stimulation of an immature gut by xanthan gum4
3. Sharp K, Ward L, Cichero J, Sopade P, Halley P. Thickened fluids and water absorption in rats
and humans. Dysphagia 2007; 22: 193-203.
4. Woods, CW, Oliver T, Lewis K, Yang Q. Development of necrotizing entercolitis in premature
infants receiving thickened feeds using Simply Thick®
Case Study
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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”
Case Study
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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, 550-680cc/day
Initial Recipe: 80 ml Neosure 22kcal
10 ml sterile water
4.5 tsp Rice cereal
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~27 kcal/oz
MD documented much improved with thickened feeds
DOL 60: RN reported difficulty w/ Dr. Browns nipple, taking
less volumes and >25 minutes to feed
Case Study
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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
3.75 tsp rice cereal
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DOL 62: New Recipe
80 ml Neosure 22kcal
10 ml sterile water
3 tsp Rice cereal
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~26kcal/oz
~25kcal/oz
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.