239 - Introduction of Oral Feeding in Premature Babies on High Flow Nasal Cannula in a Level IV Neonatal Intensive Care Unit (NICU): Quality Improvement (QI)

Poster Number: 239
Publication Number: 239.128

Hilal Yildiz Atar, Case Western Reserve University/Rainbow Babies and Children's Hospital, Shaker heights, OH, United States; Rita M. Ryan, Case Western Reserve University, Cleveland, OH, United States; Sheri E. Ricciardi, University Hospitals of Cleveland, Rainbow Babies and Children's Hospital, Brunswick, OH, United States; Madison Pihlblad, UH Rainbow Babies & Children's Hospital, Cleveland, OH, United States; Monika Bhola, UH Rainbow Babies & Children's Hospital, Cleveland, OH, United States

Background: Oral feeding (OF) is one of the most complex skills for neonates to establish to go home. Babies on higher respiratory support achieve this milestone at a later postmenstrual age(PMA). The level of respiratory support on which babies can orally feed varies among NICUs. OF does not start at our NICU until babies are on ≤2L flow of nasal cannula (NC). Earlier initiation of OF is very important to develop OF skills and avoid oral aversion.

Objective: To implement an oral feeding protocol for babies on High Flow NC (HFNC) ≤ 4L. (HFNC defined as >2L). Global aim: To reduce the PMA at the first OF attempt and PMA to reach full OF. Smart aim: To increase the introduction of OF from 0% to 20% of babies on HFNC ≤ 4L over 6 months by Feb 2022 and to 40% by Aug 2022.

Design/Methods: QI project was designed to develop and implement a new OF protocol (Fig.1) for babies on HFNC. The target patient population was babies < 1500 gr at birth who are on HFNC ≤4L, ≥32 weeks (w) PMA, tolerating ≥100 ml/kg/day (d) enteral feeds and demonstrating appropriate feeding readiness scores for 24 hours. Occupational Therapist evaluates eligible babies for feeding readiness with turning HFNC to 2L for 20 min as the first step for entry into the protocol. Before each feed, babies are monitored for 5 min on 2L for any signs of respiratory distress and kept on 2L during the OF sessions. OF attempts are advanced per protocol. Maximum volume held at 50% of the feeding volume until the baby was weaned to 2L for baseline support. PDSA cycles were introduced as needed. Balancing measures were 1) Worsening respiratory status necessitates a CXR within 48 hours after OF initiated or increase in flow > 1L from baseline or increase in FiO2 >20%, 2) Aspiration (clinically determined).

Results: Baseline data were represented by 17 babies on HFNC in 2019-2020. Aug-Dec 2021; 13 babies were eligible to enroll in HFNC feeding protocol. Ten completed the protocol without adverse events; only one had an escalation of respiratory support on day 2 of the protocol. PMA at the first oral feed attempt decreased from 42.8 to 39.9w (Table). The average days from a baseline of 2L NC (when feeds would typically have been introduced) to reaching full oral feed is 3.2d in the HFNC QI group compared to 28.9d in the traditional group (P < 0.01) (Fig. 2). PMA at discharge reduced from 48.3w to 41.6w (P < 0.01).Conclusion(s): Oral feeding in NICU babies while on HFNC can be safely implemented with QI methodology and a cautious multidisciplinary team approach. This protocol can lead babies to reach full oral feed earlier and can significantly decrease the hospital stay.
HFNC Feeding Protocol
Table 1