Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Quality Improvement Article
  • Published:

Introduction of oral feeding in premature infants on high flow nasal cannula in a level IV neonatal intensive care unit: a quality improvement initiative

Journal of Perinatology (2024)Cite this article

Subjects

Abstract

Background

Failure to reach full oral feeding remains a significant barrier for premature infants to discharge home. Postmenstrual age (PMA) at first oral feeding is significantly associated with the length of hospital stay (LOS).

Methods

Single-center QI to introduce oral feeding to infants on high-flow nasal cannula (HFNC) by reducing the flow to 2 L during feeds.

Global aim

To reduce PMA at first oral feeding and reduce the LOS.

SMART aim

To introduce oral feeds in 40% of infants who are on ≤4 L HFNC by the end of 12 months.

Results

Over 12 months, SMART aim reached with 100% enrollment. PMA at first oral feeding decreased from a median of 42.4w ((IQR) (40,46.6) to 37.8w (35.8,43.2), PMA at discharge decreased from 47w (44.6,50.7) to 42.6w (41.3,48.8).

Conclusion

Allowing oral feeding in infants while on HFNC is feasible. This approach can significantly reduce PMA at first and full oral feeding.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Fig. 1: Key driver diagram.
Fig. 2: HFNC feeding protocol.
Fig. 3: Control charts for outcome measures.

Similar content being viewed by others

References

  1. American Academy of Pediatrics Committee on Fetus and Newborn. Hospital discharge of the high-risk neonate. Pediatrics. 2008;122:1119–26.

    Article  Google Scholar 

  2. Bakewell-Sachs S, Medoff-Cooper B, Escobar GJ, Silber JH, Lorch SA. Infant functional status: the timing of physiologic maturation of premature infants. Pediatrics. 2009;123:e878–86.

  3. Edwards L, Cotten CM, Smith PB, Goldberg R, Saha S, Das A, et al. Inadequate oral feeding as a barrier to discharge in moderately preterm infants. J Perinatol. 2019;39:1219–28.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Jadcherla SR, Wang M, Vijayapal AS, Leuthner SR. Impact of prematurity and co-morbidities on feeding milestones in neonates: A retrospective study. J Perinatol. 2010;30:201–8.

    Article  CAS  PubMed  Google Scholar 

  5. Brumbaugh JE, Colaizy TT, Saha S, Van Meurs KP, Das A, Walsh MC, et al. Oral feeding practices and discharge timing for moderately preterm infants. Early Hum Dev. 2018;120:46–52.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Anderson E, Gregoski MJ, Gehle D, Head WT, Hardy KT, Chapman A, et al. Severity of respiratory disease is correlated with time of first oral feeding and need for a gastrostomy tube at discharge in premature infants born at <30 weeks of gestation. Pediatr Pul. 2022;57:193–9.

    Article  Google Scholar 

  7. de Jesus Brito S, Tsopanoglou SP, Galvão EL, de Deus FA, de Lima VP. Can high-flow nasal cannula reduce the risk of bronchopulmonary dysplasia compared with CPAP in preterm infants? A systematic review and meta-analysis. BMC Pediatr. 2021;21:1–9.

    Article  Google Scholar 

  8. Healy LI, Corcoran P, Murphy BP. High-flow nasal cannulae, bronchopulmonary dysplasia and retinopathy of prematurity. Ir Med J. 2019;112:1–7.

    Google Scholar 

  9. Hoffman SB, Terrell N, Driscoll CH, Davis NL. Impact of high-flow nasal cannula use on neonatal respiratory support patterns and length of stay. Respir Care. 2016;61:1299–304.

    Article  PubMed  Google Scholar 

  10. Canning A, Fairhurst R, Chauhan M, Weir KA. Oral feeding for infants and children receiving nasal continuous positive airway pressure and high-flow nasal cannula respiratory supports: a survey of practice. Dysphagia. 2020;35:443–54.

    Article  PubMed  Google Scholar 

  11. Leibel SL, Castro M, McBride T, Hassall K, Sarmiento K, Ye XY, et al. Comparison of continuous positive airway pressure versus High flow nasal cannula for Oral feeding Preterm infants (CHOmP): randomized pilot study. J Matern-Fetal Neonatal Med. 2022;35:951–7.

    Article  CAS  PubMed  Google Scholar 

  12. Jadcherla SR, Bhandari V “pressure” to feed the preterm newborn: Associated with “positive” outcomes? Vol. 82, Pediatric Research. Nature Publishing Group; 2017. p. 899–900.

  13. Dalgleish SR, Kostecky LL, Blachly N. Eating in “SINC”: Safe individualized nipple-feeding competence, a quality improvement project to explore infant-driven oral feeding for very premature infants requiring noninvasive respiratory support. Neonatal Netw. 2016;35:217–27.

    Article  PubMed  Google Scholar 

  14. Tubbs-Cooley HL, Pickler RH, Meinzen-Derr JK. Missed oral feeding opportunities and preterm infants’ time to achieve full oral feedings and neonatal intensive care unit discharge. Am J Perinatol. 2015;32:1–8.

    PubMed  Google Scholar 

  15. Gentle SJ, Meads C, Ganus S, Barnette E, Munkus K, Carlo WA, et al. Improving time to independent oral feeding to expedite hospital discharge in preterm infants. Pediatrics. 2022;149:e2021052023.

    Article  PubMed  Google Scholar 

  16. Ludwig S, Waitzman K. Changing feedings documentation to reflect infant-driven feeding practice. Newborn Infant Nurs Rev. 2007;7:156–60.

    Article  Google Scholar 

  17. Canning A, Clarke S, Thorning S, Chauhan M, Weir KA. Oral feeding for infants and children receiving nasal continuous positive airway pressure and high flow nasal cannula: a systematic review. BMC Pediatr. 2021;21:83. https://doi.org/10.1186/s12887-021-02531-4. Published 2021 Feb 17.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Dumpa V, Kamity R, Ferrara L, Akerman M, Hanna N. The effects of oral feeding while on nasal continuous positive airway pressure (NCPAP) in preterm infants. J Perinatol. 2020;40:909–15.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Shetty S, Hunt K, Douthwaite A, Athanasiou M, Hickey A, Greenough A. High-flow nasal cannula oxygen and nasal continuous positive airway pressure and full oral feeding in infants with bronchopulmonary dysplasia. Arch Dis Child Fetal Neonatal Ed. 2016;101:F408–11.

    Article  PubMed  Google Scholar 

  20. Wilkinson D, Andersen C, O’Donnell CP, De Paoli AG, Manley BJ. High flow nasal cannula for respiratory support in preterm infants. Cochrane Database OF Systematic Reviews. 2016;2016 Update in: Cochrane Database Syst Rev. 2023;2023.

  21. Luo K, Huang Y, Xiong T, Tang J. High-flow nasal cannula versus continuous positive airway pressure in primary respiratory support for preterm infants: A systematic review and meta-analysis. Front Pediatr. 2022;10:1–13.

    Article  Google Scholar 

  22. Greene Z, O’Donnell CPF, Walshe M Oral stimulation for promoting oral feeding in preterm infants. Cochrane Database Syst Rev. 2016;2016.

  23. Greene Z, O’Donnell CPF, Walshe M Oral stimulation for promoting oral feeding in preterm infants. Cochrane Database Syst Rev. 2023; 2023.

  24. Elsewadi BF, Samson N, Nadeau C, Vanhaverbeke K, Nguyen N, Alain C, et al. Safety of bottle-feeding under nasal respiratory support in preterm lambs with and without tachypnoea. Front Physiol. 2022;12:1–11.

    Google Scholar 

  25. Ferrara L, Bidiwala A, Sher I, Pirzada M, Barlev D, Islam S, et al. Effect of nasal continuous positive airway pressure on the pharyngeal swallow in neonates. J Perinatol. 2017;37:398–403.

    Article  CAS  PubMed  Google Scholar 

  26. Shimzu D, Araki S, Kawamura M, Kuwamura M, Suga S, Miyake F, et al. Impact of hgh flow nasal cannula oxygen on oral feeding chronic lung disease. J Occup Environ Hyg. 2019;41:131–8.

    Google Scholar 

Download references

Acknowledgements

Fig. 2 is created by biorender.com. We used the SQUIRE guideline to outline our manuscript, as the Journal of Perinatology Author Guidelines suggested. Openai.com used with rephrasing function by HYA for originally written texts. Study data were collected and managed using REDCap electronic data capture tools hosted at University Hospital. REDCap 13.5.3-2023 Vanderbilt University. Available from https://project-redcap.org/UL1TR002548.

Author information

Authors and Affiliations

  1. Rainbow Babies and Children’s Hospital, Cleveland, OH, USA

    Hilal Yildiz Atar, Rita M. Ryan, Sheri Ricciardi, Charlene Nauman, Madison Pihlblad, Taylor Forsythe & Monika Bhola

  2. Case Western Reserve University, Cleveland, OH, USA

    Hilal Yildiz Atar, Rita M. Ryan & Monika Bhola

  3. OU Health Science Center, Oklahoma City, OK, USA

    Hilal Yildiz Atar

Authors
  1. Hilal Yildiz Atar
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Rita M. Ryan
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Sheri Ricciardi
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Charlene Nauman
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Madison Pihlblad
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Taylor Forsythe
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Monika Bhola
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

MB and RMR provided leadership and supervision in designing the QI study. HYA led the study in the unit and wrote the manuscript. SR performed all initial oral feeding safety evaluations on HFNC for each infant enrolled in the new protocol. CN (nurse practitioner), MP (bedside nurse), and TF (bedside nurse) provided valuable study support with our clinical colleagues in the NICU. RMR performed the statistical analyses and created the control charts. MB and RMR contributed to major revisions of the manuscript. SR, CN, MP, and TF revised and contributed to the manuscript. All authors read and agreed to the last version of the manuscript.

Corresponding author

Correspondence to Hilal Yildiz Atar.

Ethics declarations

Competing interests

The authors declare no competing interests.

Institutional Review Board

IRB exempted the study.

Supplemental Materials

Detailed diagram for infants that were not analyzed, the bedside daily feeding evaluation forms, PDSA summary table, table with infants who needed g tube at discharge.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Yildiz Atar, H., Ryan, R.M., Ricciardi, S. et al. Introduction of oral feeding in premature infants on high flow nasal cannula in a level IV neonatal intensive care unit: a quality improvement initiative. J Perinatol (2024). https://doi.org/10.1038/s41372-024-01917-3

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1038/s41372-024-01917-3

Search

Advanced search

Quick links