Feeding During Cooling Therapy: Should we do it?

Feeding during cooling therapy for babies with HIE is a controversial topic. Past practice said no, but emerging research challenges this idea. Let’s explore the potential benefits, risks, and how to safely introduce feeding during this critical time for babies with HIE.

What is HIE?

When a baby’s brain is deprived of oxygen, a serious condition known as hypoxic-ischemic encephalopathy (HIE) may result. HIE can occur before, during, or shortly after birth, leading to potential long-term consequences for the child’s development.

The Gut-Brain Connection

The intestines and the brain are remarkably interconnected, forming what is known as the gut-brain axis. This relationship means that gut health plays a crucial role in brain development and function. The gut produces essential molecules for neurotransmitter synthesis, and beneficial gut bacteria promote healthy brain development.

Feeding During Cooling

Importance of Early Feeding in Infants with HIE

Early feeding is important for all babies in the NICU but historically we have held feedings for babies with HIE because of the concern over decreased perfusion during cooling, ischemic injury and potentially NEC. On the other hand, enteral feedings do have several benefits as discussed by Dr. Alburaki in this encore presentation on our YouTube Channel.

Feeding During Cooling: Delayed Feeding

Hypoxic-ischemic encephalopathy (HIE), a condition where the brain is deprived of oxygen, sometimes requires therapeutic hypothermia (cooling) to improve outcomes. While cooling is vital, it often leads to delayed feeding due to concerns about complications. Here’s why delayed feeding may be considered, how to safely introduce it after cooling, and resources to learn more.

Reasons for Delay

  • NEC Risk: Necrotizing enterocolitis (NEC) is a serious gut inflammation more common in premature babies. The incidence of NEC and feeding during cooling is very rare.
  • Gut Function: HIE and the cooling process itself can temporarily affect gut function, making digestion more difficult. If enteral feedings are started during cooling, most centers choose to begin slowly after the first 24 hours of life.
  • Overall Stability: Severely unstable infants may not tolerate feeding at first, and the focus remains on life support measures during the first 72 hours of life while cooling is under way.

Introducing Feeding Gradually

Once the baby is stable and older than 1 day (or when cooling has ended in some centers), careful reintroduction of feeding is crucial:

  • Small Volumes: Start with tiny amounts of breastmilk or donor milk, often given via a feeding tube but oral feedings are acceptable too if the infant is showing signs of feeding readiness.
  • Monitoring: Closely watch for signs of intolerance (abdominal distention, large or increasing residual, vomiting).
  • Patience: Progression to full feeding volume might take days or weeks depending on the baby.

Delayed Feeding Considerations

While waiting to start enteral and/or oral feedings during cooling there are other ways to support the baby and prepare them for their first feed such as:

  • Intravenous Nutrition: Ensures delivery of fluids, sugars, and nutrients to prevent deficiencies.
  • Skin-to-Skin: Promotes bonding and may have gut development benefits.
  • Non-nutritive Sucking: Allowing the baby to suck on a pacifier can support sucking reflex development.

Feeding During Cooling: The Research

While the fear of necrotizing enterocolitis (NEC) has driven the practice of withholding feeds during therapeutic hypothermia, several studies now point to the potential benefits of feeding during this treatment.

Large Retrospective Study

In a significant population-based UK study, researchers found no evidence of an increased risk of necrotizing enterocolitis (NEC) in infants who were fed during therapeutic hypothermia (cooling). This finding challenges previous assumptions and provides valuable insights into updating the standard of NICU care. With a robust study design and a large sample size, the results are compelling enough for NICU teams to reconsider old and perhaps outdated practices for babies during cooling. The absence of an increased NEC risk in the HIE population offers us evidence to update therapeutic hypothermia protocols. This study contributes to the growing body of evidence supporting the use of minimal enteral feedings during cooling for HIE.

Dr. Wissam Alburaki’s Study

This study demonstrated that babies fed during cooling reached full enteral feeds (nutrition provided entirely through the gut) more quickly than those who were not fed. Importantly, no increase in NEC risk was observed.

The Need for More Evidence

While existing research suggests that feeding during cooling may be safe and beneficial, experts like Dr. Alburaki advocate for larger, randomized controlled trials (RCTs) to provide definitive answers. These trials will help determine:

  • Safety: Whether feeding during cooling truly has no impact on NEC risk.
  • Benefits: If there are clear benefits to neurological outcomes or gut health.
  • Optimal Regimen: The ideal type of milk (breast milk, donor milk, formula), volume, and feeding frequency for infants undergoing therapeutic hypothermia.

Considerations for Practice

Until more robust evidence is available, clinicians must make decisions based on current knowledge and individual baby circumstances. Here are some things to consider:

  • Baby’s Condition: For unstable infants with very low blood pressure or other complications, withholding feeds might remain the safest option.
  • Feeding Method: Starting with small volumes of breastmilk or donor milk via nasogastric tube (NG feeding) allows for careful observation.
  • Monitoring: Closely monitoring for signs of feeding intolerance is essential.

The research challenging the traditional practice of withholding feeds during therapeutic hypothermia marks a potentially significant shift in neonatal care. It highlights the importance of ongoing research into practices that may improve both the short and long-term outcomes of babies with HIE. Clinicians should stay informed about the latest findings and advocate for evidence-based changes within their NICUs.

Frequently Asked Questions

Could feeding a baby during cooling actually worsen their condition?

While past concerns focused on necrotizing enterocolitis (NEC), recent studies indicate the risk is not increased by early feeding during cooling therapy for HIE. However, it’s crucial to closely monitor the baby for any signs of feeding intolerance and adjust the feeding plan accordingly.

Won’t the baby be too unstable to manage feeding while undergoing cooling therapy?

While it’s true that some infants may be too unstable initially, once their condition has stabilized, careful introduction of small amounts of breastmilk or donor milk (usually via feeding tube) can be attempted. Close monitoring ensures any feeding difficulties are addressed quickly.

How can I tell if a baby is ready to start feeding during cooling therapy?

For babies undergoing cooling it is essential that the team performs a comprehensive assessment of the baby’s status on a daily basis and establishes clear guidelines for introducing feeings during cooling. Many NICU’s delay enteral feedings until the 2nd day of life and then assess the infant’s overall stability, gut function, and any signs of readiness for feeding. Starting with small amounts and slow progression, along with vigilant monitoring, is key.

Do all babies with HIE need to be fed during cooling, or are there instances where we should still wait?

Decisions are always individualized. Severely unstable babies may require a temporary delay in feeding. Even for babies fed during cooling, there might be a need to pause feeds or adjust amounts based on how they respond. The overall goal is to introduce early feeding safely, when possible.


Gut-Brain Connection – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8263213/

Skin-to-Skin – https://www.youtube.com/watch?v=NaQJdlra8JQ

Necrotizing Enterocolitis in the Newborn – https://www.stanfordchildrens.org//en/topic/default?id=necrotizing-enterocolitis-in-the-newborn-90-P02388

Feeding during neonatal therapeutic hypothermia, assessed using routinely collected National Neonatal Research Database data: a retrospective, UK population-based cohort study – https://www.thelancet.com/pdfs/journals/lanchi/PIIS2352-4642%2821%2900026-2.pdf

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