When to Initiate Enteral Feeds in Neonates with HIE Undergoing Therapeutic Hypothermia
Start low-dose enteral nutrition within the first 24-48 hours of therapeutic hypothermia, then advance feeds during rewarming and after completion of the 72-hour cooling protocol. 1
Timing of Feed Initiation
Begin enteral nutrition during therapeutic hypothermia using a low-dose trophic feeding approach, as ESICM guidelines specifically recommend starting low-dose early enteral nutrition in patients receiving therapeutic hypothermia and increasing the dose after rewarming. 1
Initiate feeds within 24-48 hours of PICU admission for eligible critically ill neonates, as early enteral nutrition is recommended in term neonates who are hemodynamically stable on pharmaceutical support. 1
Do not delay feeds solely because of therapeutic hypothermia, as the rationale for withholding (decreased gut motility and required sedation) must be balanced against the benefits of early trophic feeding. 1
Evidence Supporting Early Feeding
A 2022 randomized controlled trial demonstrated that early enteral nutrition during therapeutic hypothermia is feasible and safe, with no difference in feeding intolerance rates (23.4% vs 26.7%, p=0.595) compared to delayed feeding. 2
Early feeding resulted in shorter duration of parenteral nutrition (8.81 vs 10.61 days, p<0.001), faster achievement of full enteral feeds (9.91 vs 12.24 days, p<0.001), and reduced hospital stay (12.55 vs 16.47 days, p=0.001). 2
No cases of necrotizing enterocolitis, late-onset sepsis, or death were attributed to early feeding in the intervention group. 2
Practical Feeding Protocol
During Hypothermia (0-72 hours):
Start with minimal enteral (trophic) feeds at low volumes, typically 10-20 mL/kg/day of expressed breast milk or donor human milk. 1, 2
Maintain feeds at trophic levels during the 72-hour cooling period, as tolerance to enteral feeding is impaired during hypothermia. 1
Monitor closely for feeding intolerance, recognizing that approximately 25% of infants with HIE undergoing therapeutic hypothermia will develop some degree of feeding intolerance. 2
During Rewarming (4+ hours):
Begin advancing feeds gradually as rewarming occurs over at least 4 hours at approximately 0.5°C per hour. 3, 4
Increase feeding volumes as the infant demonstrates tolerance during the rewarming phase, when gut motility improves. 1
After Rewarming:
Advance to full enteral feeds using a stepwise algorithmic approach with clear criteria for detecting and managing feeding intolerance. 1
Target full enteral feeding typically by 10-12 days of life in infants who received early feeding. 2
Contraindications to Early Feeding
Hemodynamic instability with uncontrolled shock or requirement for escalating vasoactive support. 1
Uncontrolled life-threatening hypoxemia, hypercapnia, or acidosis that has not stabilized. 1
Active gastrointestinal pathology such as suspected necrotizing enterocolitis, intestinal perforation, or obstruction. 1
Critical Pitfalls to Avoid
Do not withhold all enteral nutrition throughout the entire 72-hour cooling period, as this represents outdated practice that increases dependence on parenteral nutrition and delays achievement of full feeds. 1, 2
Avoid aggressive feeding advancement during active hypothermia, as gut motility is reduced and feeding intolerance is more common during cooling than after rewarming. 1
Do not use feeding intolerance as the sole reason to completely discontinue enteral feeds—instead, maintain trophic feeds and address the underlying cause of intolerance. 1
Recognize that feeding intolerance occurs in 25% of these infants and should be anticipated rather than viewed as a contraindication to any enteral nutrition. 2
Supportive Care Considerations
Provide adequate parenteral nutrition during the period of trophic feeding to meet full nutritional requirements, as these critically ill neonates have high metabolic demands. 2
Initiate intravenous glucose infusion to avoid hypoglycemia, which increases risk of brain injury after hypoxic-ischemic insult. 1, 5
Use breast milk as the preferred enteral feed when available, as this is the predominant practice and may offer immunological and gut-protective benefits. 6, 2
Facility Requirements
Implement feeding protocols only in level III or IV NICUs with multidisciplinary capabilities including respiratory support, intravenous therapy, continuous monitoring, and trained staff experienced in managing critically ill neonates. 1, 3, 7
Establish institutional feeding guidelines with stepwise algorithms that include eligibility criteria, timing of initiation, rate of advancement, and management of feeding intolerance. 1