44 - Safety of Early versus Delayed Oral Feeding Protocols in Infants with Congenital Diaphragmatic Hernia: A Prospective Pilot Study

Publication Number: 2041.44

Janani Rajkumar, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Beth C. Haberman, Cincinnati Children's Hospital Medical Center, CINCINNATI, OH, United States; Paul S. Kingma, Cincinnati Children's Hospital, Cincinnati, OH, United States; Beth Rymeski, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Stefanie L. Riddle, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States

Background: Infants with congenital diaphragmatic hernia (CDH) frequently face feeding challenges due to tachypnea, swallowing dysfunction, and reflux. Enteral tube feeding supports intake but may contribute to feeding intolerance and oral aversion. Feeding practices vary across centers-some initiate oral feeds early on higher respiratory support (>2 L HFNC or CPAP), postulating a reduction in oral aversion and possible earlier transition to full oral feeds. Limited evidence exists comparing the safety of these approaches. We conducted a prospective randomized pilot study to evaluate safety and feasibility of early versus delayed oral feeding in CDH.

Objective: To assess the safety of early versus delayed oral feeding protocols in infants with congenital diaphragmatic hernia, ​and ​to evaluate the impact on need for enteral feeding tube at discharge, length of stay, growth, and nutritional status.

Design/Methods: Infants ≥32 weeks with isolated CDH were randomized to early oral (EO) or delayed oral (DO) feeding. EO infants began oral feeds on ≤5 L HFNC without initial tube placement. A nasogastric (NG) tube was placed if oral progress stalled >28 days, or for central line issues, TPN cholestasis, or safety concerns. DO infants started with NG feeds, with oral feeding introduced on ≤2 L HFNC. Both groups received TPN until full enteral feeds. The primary outcome was safety, defined as respiratory escalation within 6 hours or adverse events (aspiration, malnutrition, TPN cholestasis, central line infection). Secondary outcomes included NG tube use at discharge, time to full oral feeds, central line duration, and hospital stay.

Results: The two groups (n=16; EO n=8, DO n=8) were similar in demographics, CDH severity, though EO infants had slightly lower gestational age (36.0 ± 1.6 vs 37.4 ± 0.9 weeks, p=0.04; Table 1). For the primary outcome, no safety events occurred in EO; one aspiration occurred in DO. Other adverse events, including respiratory escalation, central line infection, TPN cholestasis, and malnutrition, were absent (Table 2). DO infants were more often discharged with NG tubes (62.5% vs 12.5%, NS). Central line duration and hospital stay were slightly shorter in DO, though differences were not statistically significant; other feeding and respiratory outcomes were similar (Table 3).

Conclusion(s): Preliminary findings suggest early oral feeding in infants with CDH is safe, with lower NG dependence at discharge. Ongoing enrollment will allow estimation of effect sizes and event rates to inform a future multicenter trial evaluating safety and efficacy and guide evidence-based feeding recommendations.

Tables 1, 2 and 3
Summary of study cohort characteristics and outcomes: Table 1 presents participant demographics and baseline characteristics; Table 2 outlines primary safety outcomes; and Table 3 details secondary outcomes, including feeding and respiratory milestones.

Study Procedures
Study flow diagrams outlining inclusion/exclusion criteria, randomization, and protocol steps.

Feeding Timeline
Integrated pathway of respiratory support, weaning, and feeding milestones in early and delayed oral feeding cohorts.