Abdul Hamid, Haslina
(2022)
Feeding practices, nutrition and gastro-oesophageal reflux disease (GORD) among newborn infants in neonatal units.
PhD thesis, University of Nottingham.
Abstract
With improved care, infants born preterm are likely to survive both in high and low-resource settings. However, rate of postnatal growth failure is known to be high around the world although studies in Southeast Asia are still lacking. Effective interventions are needed to ensure that preterm infants can grow optimally. Nutrition, as one of the most important aspects in the postnatal care of preterm infants should be the top priority. Application of feeding practices varies, due to the differing protocols in neonatal units and medical conditions of the infants. In my first study (Chapter 2), nutritional practices and intakes among preterm infants in the neonatal units in Malaysia and the UK are compared and the association with growth at discharge was analysed. Results have shown that a higher number of Malaysian infants received breast milk (Malaysia: 98%, UK: 76%, p=0.001) and parenteral nutrition (Malaysia: 80%, UK: 38%, p<0.001) during admission. Malaysian infants received more protein (3.0 vs 2.7g, p=0.004) and had fewer energy and protein deficits (-191.6 kcal/kg vs -254.5 kcal/kg, -11.4 g/kg vs -15.4 g/kg) on week 1-4 of life as compared to infants in the UK unit. Despite this, more than half of infants in both units were discharged with growth failure, defined as a change in weight-for-age Z-score (WAZ) of >-1.28. Infants who had a longer length of stay had a larger drop in WAZ in the Malaysia unit. This relationship was not found in the UK cohort where protein intake and protein energy ratio (PER) were the variable that associated with changes in WAZ between birth and discharge.
From the first study, the differences in breast milk use between the neonatal units were highly apparent. Therefore, I designed the next study to look at breastfeeding in the UK neonatal unit in more detail (Chapter 3). Here, a retrospective observational study in a neonatal unit in the UK using the BadgerNet database was conducted on the prevalence of breastfeeding between 2017 and 2020. This included the duration when the COVID-19 pandemic had started, allowing me to investigate any changes of practices associated with it and the impacts on the prevalence of breastfeeding in the neonatal unit. Results have shown that there were fluctuations in the breast milk feeding prevalence during admission (adjusted OR of 0.70 (95% CI 0.44-1.12, p=0.140) and at discharge (adjusted OR of 0.96 (95% CI 0.62-1.47, p=0.844) during the early COVID-19 pandemic period as compared to the pre-pandemic period, but this was not significant. This could be due to the small sample size in this study which may not be sufficiently powered to detect a difference between the periods, or other factors such as the breastfeeding policies in the study unit which follows the WHO recommendations.
The next study also involved the use of a database as a part of the study of feeding practices in neonatal units. Gastro-oesophageal reflux (GOR) is a common condition that affects feeding practices in preterm infants and may impact their growth. It is called gastro-oesophageal reflux disease (GORD) if it presents with complications. In this study (Chapter 4), I used the National Neonatal Research Database (NNRD) to describe patterns of GORD diagnosis and use of anti-reflux medications among preterm infants in England and Wales from 2010 to 2017. Results have shown that more infants receive anti-reflux medication (10-14% of infants) as compared to those who had a GORD diagnosis (4-5% of infants). There was a decreasing trend in the use of anti-reflux medications since 2010, with the most rapid decline occurring after 2013. From this chapter, the patterns of use of different types of anti-reflux medications including Histamine-2 receptor antagonists (H2RA) and proton pump inhibitors (PPI) were also demonstrated.
In parallel to this work, I wanted to find out about the current practices and perspectives of management of GORD in preterm infants in the UK. For this, I conducted a two-part scoping survey which was undertaken as a patient and public involvement activity comprised of: i) health practitioners’ perspectives on the management of GORD and anti-reflux medications use in neonatal units, and ii) parents’ perspectives on the treatment of GORD received by preterm infants during admission in neonatal units (Chapter 5). This study demonstrated the diversity in opinions among health practitioners in determining the signs and symptoms related to GORD. However, self-reported strategies used in their clinical practice were quite consistent. The majority of respondents reported that they do not use anti-reflux medications and preferred a trial of a non-pharmacological approach before pharmacological management (n=80/154 (52%)). A few of the respondents noted that GORD is a self-resolving condition, and they would never treat it. In terms of pharmacological therapy, PPI and feed thickener with antacid (i.e. Gaviscon) were the two most popular (PPI: n=100/154 (65%), Gaviscon: n=93/154, (60%)) and prokinetics (n=27/154 (18%)) were the least medication used. The parents’ survey generally showed that parents have a certain level of understanding of the importance of using non-pharmacological strategies on initiating the treatment for GORD. However, further information and reassurance are needed to explain to parents why using medications should not be viewed as the most direct method in managing GORD in these infants.
In conclusion, my work has demonstrated findings in two main areas of neonatal research which affect all neonates (i.e. the importance of feeding and growth) and a clinical problem (i.e. GORD) that affects a large number of infants. Infants’ characteristics and feeding practices were shown to be varied between the neonatal units studied in the UK and Malaysia and these could impact nutritional requirements and growth outcomes of preterm infants. Current nutritional practices often do not meet recommended intakes and affecting their growth at discharge, especially for protein in preterm infants. However, considering the small sample size and the exploratory nature of this study, the findings should be interpreted with cautions, while also taking into consideration that feeding plan, growth and discharge decision in the units is not a linear pathway and there are other external factors that might affect one pathway or another. In terms of the prevalence of breastfeeding in the neonatal unit in the UK, this study has shown that the effect of COVID-19 pandemic on the rate of breastfeeding was not apparent and the fluctuations were not statistically significant. Larger sample size with the inclusion of more study units might provide a better analysis of the variations observed. Lastly, in the study of GORD and the use of anti-reflux medications among preterm infants, I have shown a discordance between GORD diagnosis and the use of anti-reflux medications. This could be a reflection of difficulties in diagnosing the condition and the lack of evidence-based management strategies. The parents and health care professionals survey supported this. Further research should be guided to design clinical diagnostic tools and evidence-based strategies to manage GORD in preterm infants.
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