Table 2 Summary of primary outcomes (PO)

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.