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Table 3 Summary of secondary outcomes (SO) 1, 2 and 3

From: Oral feeding for infants and children receiving nasal continuous positive airway pressure and high flow nasal cannula: a systematic review

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

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

  1. OPA oropharyngeal aspiration, BPD bronchopulmonary dysplasia, CPAP continuous positive airway pressure, HFNC high flow nasal cannula, HHHFNC heated and humidified high flow nasal cannula, LFNC low flow nasal cannula, LFO low flow oxygen, NC nasal cannula, NIPPV noninvasive positive-pressure ventilation, BiPAP Bilevel positive airway pressure, AVAPS average volume-assured pressure support