Elsevier

Journal of Neonatal Nursing

Short-term feeding outcomes after neonatal brain injury

Abstract

Background

Although brain injury is known to be associated with feeding outcomes in preterm and unwell neonates, these groups are frequently excluded from studies of neonatal feeding development. This paper aims to identify the short-term feeding outcomes of infants with neonatal brain injury.

Methods

A retrospective cohort analysis was undertaken to ascertain the incidence of feeding disorders (full/partial tube feeding at 40 weeks) among infants with brain injury admitted to a UK neonatal unit between 2013 and 2017.

Results

202 surviving infants with neonatal brain injury were included in the study. Feeding disorders were common among infants with brain injury (preterm 34%, term 34%) compared to infants without significant neurological comorbidities (preterm 9%, term 3%). The likelihood of feeding disorders increased with injury severity.

Conclusions

All infants with neonatal brain injury should have access to a specialist feeding therapist to maximise their feeding potential and provide support to families.

Introduction

Brain injuries occur during or soon after birth in 5.19 per 1000 live births in England (Gale et al., 2018). The impact of these brain injuries on infant health and neurodevelopment is dependent on a range of factors, including the type and severity of injury and the gestational age at which the injury occurs. Brain injuries in preterm infants typically result from haemorrhage; most commonly intraventricular haemorrhage (IVH) stemming from the germinal matrix (Gale et al., 2018; Webster, 2020). In term infants, the most common form of brain injury is hypoxic ischaemic encephalopathy (HIE) (Gale et al., 2018). Other causes of neonatal brain injury affecting both term and preterm infants include infections of the central nervous system, non-IVH forms of intracranial haemorrhage (ICH), and stroke (Gale et al., 2018). Areas known to be damaged by neonatal brain injury include the cortex, basal ganglia and thalamus, brainstem, subcortical white matter, and the cerebellum (Bano et al., 2017; Fumagalli et al., 2015; Inder et al., 2018; Jeong et al., 2016; Rutherford et al., 2010; Tam et al., 2011). These are areas of vital importance to the control of feeding and swallowing (Ahn and Musso, 2018; Kashou et al., 2017; Mourão et al., 2017). It is, therefore, unsurprising that brain injury is one of several important predictors of feeding outcomes in infants admitted to a neonatal unit (Edney et al., 2019; Harding et al., 2012, 2015; Hawdon et al., 2000).

There is increasing recognition that early therapy interventions can capitalise on the potential for neuroplastic change and improve outcomes for infants at risk of neurodisability (DeMaster et al., 2019; Hutchon et al., 2019; Khurana et al., 2020; Kolb and Gibb, 2011; Morgan et al., 2013). Such interventions may improve feeding outcomes for infants with neonatal brain injuries; however, this group is typically excluded from studies of neonatal feeding development and feeding interventions. This exclusion has resulted in a lack of understanding about neonatal feeding disorders specific to neurological impairment, hindering intervention development and clinical practice. The most detailed studies in this area have focused on HIE and stroke and provide evidence that neonatal brain injury can result in impaired oral motor skills and pharyngeal swallow function, reduced opportunities for consistent oral practice and associated motor learning, and prolonged reliance on tube feeding (Barkat-Masih et al., 2010; Harding et al., 2015; Krüger et al., 2019; Martinez-Biarge et al., 2012). However, comparison of the feeding disorders reported in these groups is hampered by a lack of agreed definitions, differences in the methods used to measure outcomes, and limited descriptions of the severity, characteristics, and associated physiology of the feeding disorder.

A consensus definition statement and conceptual framework has been published that identifies the medical, nutritional, feeding skill, and psychosocial aspects of oral intake disturbance that define a paediatric feeding disorder (Goday et al., 2019). Use of such a framework in neonatal brain injury research would clarify which types of brain injury are most associated with feeding disorders, what pathophysiology underlies these disorders, and how these disorders impact on infants and their families. These data, in reliable form, are needed to develop appropriate interventions that target the specific feeding and swallowing disorders experienced by these groups.

This study aims to identify the incidence and types of brain injuries experienced by infants admitted to a Level 3 neonatal unit (including intensive care, high dependency, and special care) and the feeding outcomes of neonates with brain injuries at 40 weeks corrected age and at discharge. The findings of this study will be used to inform targeted intervention development and studies of intervention effectiveness.

Section snippets

Design

Retrospective cohort study.

Setting

A Level 3 Neonatal Unit in an acute hospital in north-west England.

Sample

Data were collected for all infants admitted to the neonatal unit from January 1, 2013 to December 31, 2017 who experienced HIE, IVH, ICH, PVL, stroke, or central nervous system infection prior to or during their admission. Infants were excluded if data regarding gestational age at birth, diagnostic group, or feeding outcome were not available. Infants with diagnoses in addition to brain injury were

Sample

After removal of duplicates, 2499 infants were admitted to the unit during the 5-year study period and screened for inclusions. A total of 202 infants with brain injury were identified and included in the study (8% of admissions). Brain injury types included: IVH (53%), HIE (30%), infection (7%), stroke (3.5%), multiple brain injury types (3%), PVL (2%), and ICH (1.5%). IVH, PVL, and ICH occurred only in preterm infants, while HIE and stroke tended to affect term born infants (Table 1). Data

Discussion

In this study, infants with neonatal brain injury were found to be at increased risk of being partially or fully reliant on non-oral nutrition at 40 weeks corrected age and at discharge when compared to preterm or unwell term infants without significant neurological co-morbidities. It is interesting to note the trend towards higher risk of feeding disorders in infants with milder forms of brain injury. This is in keeping with an increasing body of literature suggesting that milder forms of IVH

Conclusions

Neonatal brain injuries of all types and severity levels can increase the risk of feeding disorders in the neonatal phase, preventing progression to full oral feeding and prolonging admission to the neonatal unit. Access to specialist feeding therapists should be made available to all infants with neonatal brain injury in order to maximise the infant's feeding potential and support their families, while on the neonatal unit and after discharge.

Funding

This work was support by a Collaboration for Leadership in Applied Health Research and Care North West Coast Research Fellowship Internship. The study design and procedures were approved by North East - Tyne & Wear South Research Ethics Committee (Approval number: 19/NE/0273).

Declaration of competing interest

None.

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