Background
Methods
Results
Study characteristics
Author, year | Study design and setting | Participants (sample size, age and condition) | Type of respiratory support, flow/pressure | Details of oral feeding | Main outcomes |
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Bapat 2019 [23] | Quality improvement project (non-contemporary cohort comparison study); NICU | 279 infants < 32 + 6 weeks GA (198 had BPD); baseline group 92 infants (63 had BPD); SIMPLE group 187 infants (135 had BPD) | CPAP (H2O not reported) | Oral feeding on CPAP; Guideline for feeding strategies on respiratory support; once a day oral feeding by occupational therapist, intensive cautious early feeding opportunities. | Days to full enteral feeding; days to first oral feeding; days to full oral feeding; ventilation duration; growth milestones; discharge milestones including LOS |
Dalgleish 2016 [10] | Quality improvement project (non-contemporary cohort comparison study); NICU | 196 infants born < 32 weeks with respiratory morbidity | CPAP (cmH2O not reported) HFNC> 1.5 L/min | Cohort 1: No oral feeding on NIV = 91; Cohort 2: Oral feeding on NIV = 105; Oral feeding on nCPAP as per novel algorithm ‘Eating in SINC: Safe Individualised Nipple-Feeding Competence’ | GA at first oral feed; days of respiratory support; respiratory support at first NF; LOS; safety |
Dumpa 2020 [24] | Retrospective cohort study; NICU | 99 infants < 32 weeks GA | CPAP 5-8cmH2O | Group 1 (oral feeding commenced on CPAP) = 39; Group 2 (oral feeding commenced when off CPAP); objective oral feeding assessment developed by NICU staff. | Duration to achieve full oral feeding; LOS; respiratory morbidities |
Ferrara 2017 [14] | Prospective cohort study; NICU | 7 infants with a PMA > 34 weeks 6 preterm, 1 term (34.1–43.2 weeks CGA) | CPAP 5cmH2O LFNC 1 L/min | Oral feeding on CPAP; Infant swaddled positioned in a sitting position in a tumbleform infant seat, bottle offered for 90 s by a single feeding and swallowing specialize. | Incidence of mild and deep laryngeal penetration, aspiration and nasopharyngeal reflux on VFSS |
Glackin 2017 [25] | Randomised control trial; NICU | 44 infants born before 30 weeks nCPAP = 22; HFNC = 22 | nCPAP (cmH2O not reported, stated ‘current setting’); HFNC commencing at 7 L/min | Oral feeding on CPAP and HFNC; Oral feeds offered in both groups at least once every 72 h and additional feeds offered when infants demonstrated feeding cues. | Duration to first oral feed; duration to full oral feeds; duration of resp. support; CNLD; LOS; episodes of apnoea |
Hanin 2015 [26] | Retrospective cohort study; NICU | 53 infants with BPD 37-42wks PMA; | nCPAP 6-8cmH2O | Orally fed on nCPAP = 26; Gavage fed on nCPAP =27; All oral feedings were done by a trained neonatal OT; clinical assessment completed prior to initiation of feeding therapy; based of SOFFI method; oral feeding session no more than 30mins, one session per day, 3–5 times per week. | Duration to full oral feeds; LOS; duration of nCPAP; safety metrics; readmission rate |
Jadcherla 2016 [27] | Prospective case control study; NICU | 38 infants with BPD 28 + 0.7wks GA; 39-43wks CGA at evaluation; nCPAP = 9; NC = 19; RA = 10 | nCPAP 6-8 cm H2O; NC 0.1–2.0 L/min | Graded sterile water infusions via syringe of 0.1, 0.3 and 0.5 mL to the pharynx for infnats on CPAP. | Effects of pharyngeal stimulation on the initial and terminal pharyngoesophageal and respiratory responses |
La Tuga 2019 | Retrospective case control study; NICU | 243 infants < 32 weeks GA who required CPAP at 32 weeks PCA | CPAP (cmH2O not reported) | No CPAP first oral feed GA 27 (24–32) wks; CPAP first oral feed GA 26 (23–32) wks 31% (n = 76) received first oral feed on CPAP; Oral feeding defined as any feeding taken by mouth > 5 mL | Length of stay; duration of resp. support; age at first oral feed; age at full oral feeds; duration to full oral feed; aspiration pneumonia |
Leder 2015 | Prospective cohort study; NICU & adult ICU | 100 participants: 50 neonates (CGA range 33w7d-49w3d) & 50 adults | HFO2-NC 2-3 L/min | Oral feeding on HFNC. 17 neonates had oral feeding. Decisions to initiate oral feeding made jointly by neonatology and nursing using criteria. | Successful initiation of oral feeding; age at initiation of oral feeds |
Leibel 2020 [33] | Randomised control pilot study; NICU | 25 infants born < 28 weeks GA, 34 weeks PMA, requiring CPAP or HFNC’; CPAP n = 12; HHHFNC n = 13 | CPAP >5cmH2O; HHHFNC > 5 L/min | Infants on CPAP were placed on LFNC (up to 2 L/min) for oral feeding, infants on HHFNC had flow reduced to 2 L/min for oral feeding | Days to full oral feed; weight gain; feeding type; feeding intolerance; NIV support at end of trial; incidence of CLD; PMA at conclusion of trial |
Leroue 2017 [28] | Retrospective cohort study; PICU | 562 children older than 30 days to > 10 years (median age 2 yrs) requiring NIPPV, majority had a primary diagnosis of bronchiolitis or viral pneumonia | NIPPV = HHFNC, CPAP, BiPAP, AVAPS; CPAP or bilevel support 6-8cmH2O; HHFNC (flow rate/s not reported) | Oral feeding on NIPPV. 305 (54%) had oral intake. | Early EN; time to goal EN rate; adequacy of EN; frequency of EN interruptions > 6 h; AEs |
Shadman 2019 [29] | Retrospective cohort study; intensive and general care units, children’s hospital | 123 children aged 1 to 24 months with bronchiolitis treated with HFNC | HFNC (flow rate/s not reported) | Oral feeding on HFNC. 78 (63%) were fed: 50 (41%) were exclusively orally fed and 28 (23%) had mixed oral and tube feeding. | Time to discharge after HFNC cessation; aspiration; intubation after HFNC; seven-day readmission |
Shetty 2016 [8] | Retrospective cohort comparison study; NICU | 116 infants with BPD (24-32wks GA); nCPAP =72; nCPAP/HHFNC =44 | CPAP 4-6cmH2O; HHFNC 2-8 L/min | Oral feeding on HFNC (no oral feeding on CPAP); Infants on HFNC were referred to SLT service from 34 weeks GA to assess readiness to cope with oral feeding. | Age at first oral feed; age at full oral feeds; duration and type of resp. support; LOS |
Shimizu 2019 [30] | Retrospective case control study; NICU | 45 infants (< 34 weeks PMA; GA 23.1–39.6 weeks GA) with very low birth weight and chronic lung disease | HFNC 2 L/kg/min | Oral feeding on HFNC n = 11 (GA 27.4; 23.1–32.0 weeks); oral feeding without HFNC n = 34 (31.2; 23.7–39.6 weeks); Oral feedings offered to infants with stable breathing after 34 weeks PMA, after oral feeding skill evaluation by physical therapists. | Duration to first oral feed; duration to full oral feeds; clinically significant aspiration pneumonia |
Slain 2017 [9] | Retrospective cohort study; PICU | 70 children < 24 months (median age of 5 months) with bronchiolitis | HFNC 2-4 L/min; 5-6 L/min; > 7 L/min | Oral feeding on HFNC; 89% fed orally. | Incidence of feeding-related AEs; LOS; duration of HFNC |
Sochet 2017 [31] | Prospective cohort study; PICU | 132 children (1 month to 2 yrs) with bronchiolitis | HFNC 4-13 L/min (0.3–1.9 L/kg/min) | Oral feeding on HFNC; 97% fed orally. | Incidence of aspiration-related respiratory failure |
Main outcomes
Quality of individual studies
Results of individual studies
Analysis of primary outcomes
Study, year | Respiratory support | PO1: Full oral feeding | PO2: Partial oral feeding (including initiation of oral feeding) | PO3: OPA- instrumental assessment | Conclusion/s |
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Bapat 2019 [23] | CPAP (cmH2O not specified) | Full oral feeds were achieved significantly earlier by infants with mild to moderate BPD (but not for severe BPD) in the SIMPLE feeding program. Baseline group median 84 DOL (range 90 + 32DOL), SIMPLE group median 81 DOL (range 85 + 36DOL) | First oral feed milestone achieved at an earlier age for the SIMPLE feeding group for all 3 severity categories (mild, mod, severe BPD). Baseline group median 72 DOL, SIMPLE group median 64 DOL. | No | Intensive cautious early feeding opportunities may be helpful in modifying the aerodigestive outcomes among BPD patients. The SIMPLE feeding strategy advances maturation and acquisition of feeding milestones irrespective of the severity of BPD and impacts LOS. |
Dalgleish 2016 [10] | CPAP (pressure/s not reported) HFNC > 1.5 L/min | Not reported | Age at first oral feed GA mean 32 weeks, 4 days; 65 (61.9%) of the 105 participants were no longer receiving nCPAP when oral feeds were initiated. | No | Project suggests the consistent approach for NF may be safe in the short-term, however is a pilot study with plans for further evaluation of safety and efficacy of the SINC strategy |
Dumpa 2020 [24] | Orally fed while on nCPAP 5-8cmH2O (group 1) vs oral feeding after ceasing nCPAP (group 2) | Group 1 took longer to achieve full oral feeding (median 16 days) vs group 2 (median 10 days) vs group 3 (PMA > 34 weeks, off nCPAP, positive oral feeding cues) (median 10 days). However PMA at full oral feeding reached was not significantly different between the groups. | Infants in group 1 had an earlier initiation of oral feeds (median PMA 35.2 weeks), as expected, compared with group 2 (median PMA 35.8 weeks) and group 3 (median PMA 35.9 weeks). | No | Delaying oral feeding until ceasing nCPAP did not result in feeding-related morbidities. Caution recommended when initiating oral feedings in preterm infants on nCPAP without evaluating the safety of the infants and their readiness for oral feeding. |
Ferrara 2017 [14] | CPAP 5cmH2O vs LFNC 1 L/min | Not reported | Tolerating at least 50% of TFI orally | Yes | Oral feeding while on-nCPAP significantly increases the risk of laryngeal penetration and tracheal aspiration events. Recommend caution when initiating oral feedings on nCPAP. |
Glackin 2017 [25] | nCPAP (pressure/s not reported) vs HFNC commencing at 7 L/min | Number of days to achieve full oral feeding was found to not be significantly different between the nCPAP and HFNC cohorts (HFNC 36.5 days + 18.2; nCPAP 34.1 days + 11.2; p = 0.61). | First oral feed (days from enrolment at 32 weeks CGA) for infants receiving nCPAP (9.3 + 6.5 days) and HFNC (10.9 + 4.8 days), p = 0.37. 6 infants in nCPAP group (n = 22) and 1 in HFNC group (n = 22) were off respiratory support when the first oral feed was provided. | No | Preterm infants treated with HFNC did not achieve full oral feeding more quickly than infants treated with nCPAP. |
Hanin 2015 [26] | nCPAP-oral (6-8cmH2O) vs nCPAP-gavage | nCPAP-oral fed group achieved full oral feeding 17 days earlier (median) compared with the infants on nCPAP that were not orally fed and gavage/tube fed only (nCPAP-oral 120.5 DOL, 41.6 weeks PMA; nCPAP-gavage 137 DOL; 45.5 weeks PMA; p > 0.05). | Not reported | No | Controlled introduction of oral feedings in infants with BPD during nCPAP is safe and may accelerate the acquisition of oral feeding milestones. |
Jadcherla 2016 [27] | nCPAP (6-8 cm H2O) NC (0.1–2.0 L/min) Room air | Not reported | Graded sterile water infusions via syringe of 0.1, 0.3 and 0.5 mL to the pharynx. | No | The current study lends support to provide mechanistic basis and rationale for supporting “controlled and regulated” oral feeding during nCPAP or HFNC. |
La Tuga 2019 | CPAP (pressure/s not reported) vs no CPAP first oral feed | Infants who started oral feeding on CPAP took longer to attain full oral feeding (median 24 days vs 18 days) and achieved full oral feeding at a later PCA (median 37.6 weeks vs 36.6 weeks). | 31% (n = 76) received first oral feeding on CPAP; Infants who received first oral feeding on CPAP had younger GA, lower birthweight, smaller length and head circumference than those without oral feedings on CPAP. Both infants on and off CPAP were of comparable weight and PCA at the time of first oral feeding. | No | Infants who began oral feeding on CPAP had lower GA and longer duration of intubation than infants who started oral feeding off CPAP. |
Leder 2016 [16] | HFNC 2-3 L/min | Not reported | Successful initiation of oral feeding in 17 of 50 (34%), mean CGA 35 weeks, 4 days . Remaining 34 infants (mean CGA 33 weeks, 4 days) remained nil per oral due to prematurity or medical conditions precluding oral feeding. Age differences were noted for the neonates who initiated oral feedings (greater GA, CA) however this was not statistically significant. | No | It is not the use of HFNC per se but rather patient-specific determinants of feeding readiness and underlying medical conditions that impact decisions for oral alimentation. |
Leibel 2020 | On CPAP minimum of 5cmH2O (orally fed on LFNC < 2 L/min) vs on HFNC minimum of 5 L/min (orally fed on 2 L/min) | Infants randomised to the HFNC group reached full oral feeds 7 days sooner than those randomised to CPAP. Days to full oral feeds: nCPAP 36.5 days (25.5 median); HFNC 29 days (20 median), p value 0.35. | Not reported | No | Feasible to perform an adequately powered RCT to confirm or refute that HFNC is associated with achieving oral feeds earlier. |
Leroue 2017 [28] | NIPPV (HFNC, CPAP, BiPAP, AVAPS); CPAP: 6-8cmH2O; HFNC: flow rate/s not reported | At time of EN initiation: 42% HHFNC, 13% CPAP, 32% bi-level support; 54% were provided with nutrition orally | No | EN can be provided to children on NIPPV, and in certain subsets, goal EN can be achieved while in the PICU. However, these results generate additional areas for future study about the safety and effectiveness of this practice. | |
Shadman 2019 [29] | HFNC (flow rate/s not reported) | 41% (50/123) of children treated with HFNC were exclusively orally fed. Compared to children who were not fed, time to discharge following HFNC completion was significantly shorter for those who were exclusively orally fed. | 23% (28/123) of children treated with HFNC had mixed oral and tube feedings. | No | Children fed while receiving HFNC for bronchiolitis may have shorter time to discharge than those not fed. |
Shetty 2016 [8] | nCPAP (4-6cmH20) vs nCPAP then transferred to HFNC 2-8 L/min; No oral feeding on nCPAP, oral feeding on HFNC only. | Age to achieve full oral feeding was not found to be significantly different in either group. Sub-analysis of infants receiving nCPAP-only or nCPAP-then-HFNC beyond 34 weeks PMA showed that full oral feeding was achieved significantly earlier in the nCPAP-then-HFNC group (nCPAP 41 weeks PMA, 111 days of life [DOL]; nCPAP/HFNC 39.43 weeks PMA, 92 DOL). | Postnatal age at which oral feeds first trialed for infants requiring respiratory support after 34 weeks PMA was significantly earlier in the nCPAP/HFNC group (median PMA 34.71 weeks) vs the nCPAP group (median PMA 36.71 weeks). The nCPAP group was born at an earlier gestational age and lower birth weight. | No | In infants with BPD who required respiratory support beyond 34 weeks PMA, use of nCPAP then HFNC was associated with earlier establishment of full oral feeds. |
Shimizu 2019 [30] | HFNC (2 L/kg/min) vs no HFNC first oral feed | Similar ages for achievement of full oral feeding between the two groups 38.6 (34.4–42.3) vs 36.7 (34.6–44.4) weeks PMA respectively (p = 0.29). Duration from birth until the achievement of full oral feeding was earlier in the non-HFNC group than in the HFNC group (38 vs 77 median days, p = 0.03). The HFNC were born at a lower GA, lower BW and demonstrated more immature respiratory function than the non-HFNC group. | No significant difference in timing of first oral feed between the two groups: 35.3 (33.0–38.1) vs 35.5 (33.7–42.4) weeks PMA, respectively (p = 0.91) No difference between the two groups in duration from birth to the timings of the first oral feed: 52 (14–97) vs 31.5 (1–88) days, respectively (p = 0.07) | No | Initiation of oral feeding of VLBWIs on HFNC might be safe and might accelerate the achievement of oral feeding milestones. |
Slain 2016 | HFNC 2-4 L/min vs 5-6 L/min vs > 7 L/min | Children were fed in 501/794 (63%) of shifts: 434 oral, 67 NG/ND/GT; EN was provided ‘mostly orally’ (5 children (7%) received NG or ND feeds, 3 children (4%) received GT feeds | Not reported | No | In this small patient cohort at a single institution, AEs were rare and not related to the delivered level of HFNC respiratory support. Children who were fed earlier in their PICU admission had shorted PICU stays. |
Sochet 2017 [31] | HFNC 4-13 L/min (0.3–1.9 L/kg/min) | 97% received EN by mouth, 3% by NGT | Not reported | No | Oral nutrition was tolerated across a range of HFNC flow and respiratory rates, suggesting the practice of withholding nutrition in this population is unsupported. |
Analysis of secondary outcomes
Study, year | Respiratory support | SO1: Clinical signs of OPA | SO2: Aspiration pneumonia or antibiotics for suspected aspiration pneumonia | SO3: Decrease in respiratory status/signs of respiratory distress |
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Bapat 2019 [23] | CPAP (cmH2O not specified) | Not reported | Not reported | Not reported |
Dalgleish 2016 | CPAP (pressure/s not reported), HFNC > 1.5 L/min | No cases of suspected aspiration based on clinical or radiographic observation and no safety concerns noted by nurses, consulting OTs or neonatologists based on individual assessment. | No cases of suspected aspiration based on clinical or radiographic observation. | Oral feedings were stopped at the first sign of stress, which resulted in no infant having worsening respiratory status or physiological instability. |
Dumpa 2020 [24] | Orally fed while on nCPAP 5-8cmH2O vs oral feeding after ceasing nCPAP | Not reported | Not reported | Not reported |
Ferrara 2017 [14] | CPAP 5cmH2O vs LFNC 1 L/min | Not reported | Not reported | Not reported |
Glackin 2017 [25] | nCPAP (pressure/s not reported) vs HFNC commencing at 7 L/min | Adverse events, eg. desaturation and bradycardia, were recorded on proforma data sheets for every feed offered. No details were provided in results- authors stated no adverse outcomes or events in any of the infants. | No cases of aspiration following oral feeds on nCPAP or HFNC | No acute respiratory deterioration occurred in any of the infants in either group. |
Hanin 2015 [26] | nCPAP-oral (6-8cmH2O) vs nCPAP-gavage | Frequency of physiologic and behavioral distress for all feeding sessions (n = 218) that resulted in termination of the bottle feeding: Apnoea or bradycardia events (2.7%, n = 6); Desaturation to less than target FiO2 saturation (11%, n = 25); > 1 episode of coughing or gagging (0.4%, n = 1). | No clinically significant aspiration pneumonia No infants received any antibiotics during the period of nCPAP oral feeding due to suspected aspiration pneumonia. | Oral feedings were terminated when the following occurred: increase in respiratory rate or work of breathing (14%, n = 30). Three events (1%) required supplemental FiO2; one infant had changes in chest x-ray. |
Jadcherla 2016 [27] | nCPAP (6-8 cm H2O) vs NC (0.1–2.0 L/min) vs room air | Not reported | Not reported | Not reported |
La Tuga 2019 | CPAP (cmH2O not reported) vs no CPAP first oral feed | Not reported | No significant difference in aspiration pneumonia between infants who initiated oral feeding on CPAP (n = 76) compared to infants that did not begin oral feeding on CPAP (n = 167), with only one case of aspiration pneumonia reported in each cohort. | Not reported |
Leder 2016 [16] | HFNC 2-3 L/min | 17 NICU patients had ‘successful initiation of oral alimentation’ which was defined as swallowing without overt signs of dysphagia eg. cough or worsening respiratory status. | Not reported | Not reported |
Leibel 2020 [30] | On CPAP minimum of 5cmH2O (orally fed on LFO < 2 L/min) vs on HHHFNC minimum of 5 L/min (orally fed on 2 L/min) | Feeding intolerance defined as “holding or decreasing the volume of feeds by the medical team due to emesis or aspiration (defined as coughing or choking during a feed)” nCPAP 8.33% (1/12), HHHFNC 30.77% (4/13) Aspiration vs emesis not differentiated. | None of the infants developed aspiration while on short-term LFO for the purpose of oral feeding. | None of the infants developed cardio-respiratory decompensation while on short-term LFO for the purpose of oral feeding. |
Leroue 2017 [28] | NIPPV (HFNC, CPAP, BiPAP, AVAPS); CPAP: 6-8cmH2O; HFNC: flow rate/s not reported | Not reported | Development of pneumonia not present at admission (n = 54). Difficult to discern whether a complication of feeding or natural progression of the disease. | 3% (n = 16) of patients receiving NIPPV (n = 562) required intubation after EN initiation, 4 for elective procedures and 12 for progressive respiratory failure. |
Shadman 2019 [29] | HFNC (flow rate/s not reported) | Not reported | One fed infant had antibiotic initiation with radiological documentation of possible pneumonia and physician documentation of suspected aspiration pneumonia. | Not reported |
Shetty 2016 [8] | nCPAP (4-6cmH20) vs nCPAP then transferred to HFNC 2-8 L/min | Not reported | Not reported | Not reported |
Shimizu 2019 [30] | HFNC (2 L/kg/min) vs no HFNC first oral feed | Not reported | No clinically significant aspiration pneumonia in the HFNC group during oral feeding. | No increase in oxygen requirements between the oral feeding on HFNC vs oral feeding without HFNC groups. |
Slain 2016 | HFNC 2-4 L/min vs 5-6 L/min vs > 7 L/min | No documented aspiration or choking events. Data extracted from nursing documentation regarding 70 children who had enteral feeding (89% oral). | Not reported | Feeding-related adverse events (AEs) were categorized as ‘respiratory distress’ (n = 9) or ‘emesis’ (n = 20). AEs documented in 29 of 501 (6%) nursing shifts (434 shifts with oral feeds). |
Sochet 2017 [31] | HFNC 4-13 L/min (0.3–1.9 L/kg/min) | Not reported | Development of aspiration-related respiratory failure occurred in 1 (0.8%) patient | Interruptions in enteral nutrition occurred in 12 (9.1%) children, 10 for tachypnoea, 1 for increased work of breathing |