This document discusses feeding strategies for neonates with abnormal umbilical artery Doppler findings. It begins by noting that about 6% of high-risk pregnancies have abnormal Doppler flow, increasing the risk of feeding difficulties. It then discusses the pathophysiology of abnormal Doppler flow and its effects on the intestine. Several feeding strategies are proposed, including starting minimal enteral nutrition from birth, progressively increasing volumes over time, using breast milk when possible, and monitoring for intolerance. The discussion section notes limited evidence, and the results section compares early versus delayed feeding, finding earlier feeding led to shorter time to full feeds and hospital stay without increasing complications.

1. Feeding of Neonates with
Umbilical Artery Doppler
Abnormalities
DR PRAKASH MAN SHAH
JR2

2. INTRODUCTION
• 6% of high-risk pregnancies have abnormal umbilical Doppler flow,
• increasing the risk of enteral feeding difficulties like feed intolerance
and necrotizing enterocolitis in preterm children.
• These anomalies cause excessive delay in enteral feed advancement,
extending hospital stays and feeding time.

3. Pathophysiology of abnormal doppler flow
• Fetal growth restriction is caused by abnormalities in the placenta
and increased vascular resistance.
• Fetal hypoxia and hypercarbia cause cerebral vasodilatation, while
increased sympathetic activity leads to peripheral vascular resistance.
• This results in a preference for blood flow to brain, heart, and
adrenals, causing reduced intestinal perfusion and hypoxic injury.

4. • Fetal hypoxia and vascular resistance cause intestine hypoxic injury,
causing motor, secretory, and mucosal dysfunction, making it
vulnerable to bacterial colonization.
• Circulatory changes in infants with AREDF persist after birth, with
reduced blood flow in the superior mesenteric artery and celiac axis.
• High metabolic demands and compromised gut perfusion affect
intestine oxygenation, while intestinal stasis and immunological
factors contribute to NEC development.

7. Feeding strategies in infants with AREDF
When to start minimal enteral nutrition (MEN) in infants with AREDF?
• Infants with AREDF should receive MEN from birth, but the duration
and timing of MEN before progressive enteral feeding are
controversial.
• MEN is initiated on day 1 in neonates with 1250 g or more birth
weight and after 24 hours in those weighing less.

8. When to start progressive enteral feeding?
• Delayed progressive enteral feeding may benefit infants with AREDF,
potentially reducing NEC risk but extending hospital stay duration.
• ADEPT trial shows feed volumes increased progressively from second
day in neonates with birth weight > 1000 g.
• In neonates born beyond 29 weeks of pregnancy, we increase feed
volume the following day (if they tolerated MEN well); in neonates
born at or before 29 weeks of pregnancy, we continue MEN for 48
hours before increasing feed volume.

9. How to advance?
• Feed advancement rate varies; 10-20 mL/kg/day for infants under
1000g, 20-30 mL/kg/day for above 1000g.
• A study found no increase in NEC or feed intolerance in infants with
slow vs. rapid advancement of enteral feeding in birth weight groups.
However, the number of infants with growth restriction or abnormal
antenatal Doppler was small in the included studies.
• In neonates weighing less than 1250 g at birth, we increase feed
volume by 10 to 20 mL/kg/day, and in neonates weighing 1250 g or
more, we increase feed volume by 20 to 30 mL/kg/day.

10. Which milk to start?
• Breast milk is preferred for preterm infants, while mother's milk is
preferred over donor human milk. Exclusive human milk feeding
reduces NEC incidence.

11. How to monitor?
• Infants with AREDF are monitored for feed intolerance in the same
way as other preterm or LBW neonates. If there is any feed
intolerance, it must be addressed in accordance with the protocol on
"Feeding of LBW infants."

12. How to fortify?
• Once the newborn has consumed 100 mL/kg/day of feeding,
fortifying breast milk is preferred. Fortification, however, began in the
ADEPT study once the infants achieved 150 mL/kg/day.
• Infants with AREDF have a two-fold higher risk of developing NEC
compared to normal umbilical Doppler flow. This delays enteral
feeding initiation, resulting in longer hospital stays and longer feeding
durations.

19. Discussion:
• There is limited evidence from randomised controlled trials on which
to base decisions regarding feeding policy in high risk preterm infants.
This multicentre trial will help to guide clinical practice and may also
provide pointers for future research.

21. Results:
• The 50 neonates were enrolled. Baseline characteristics were
comparable.
• A significantly higher time to full feeds was recorded in the delayed
feeding regimen by a mean of 3.9 days.
• The duration of hospital stay was significantly higher for delayed
feeding regimen (+12.7 days). Days of mechanical ventilation were
also significantly higher (+1.6 days) in the neonates in delayed feeding
group.
• There was no difference in the incidence of feed intolerance, NEC,
incidence of culture positive sepsis and mortality across the two
regimens, however neonates in the delayed feeding group needed
longer support with parenteral nutrition.

22. Conclusions:
• Early feeding will lead to earlier time to full feeds and decreased
duration of hospital stay without additional increase the incidence of
feeding intolerance and NEC in neonates with AEDF/REDF.
• Individualized feeding strategy in these compromised neonates
should be the primary objective to optimize outcomes.

23. THANK YOU