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

Background: Infants with congenital diaphragmatic hernia (CDH) face significant feeding challenges. 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. Others follow a more conservative approach, delaying oral feeds until lower respiratory support. However, limited evidence compares the safety of these approaches.

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

Design/Methods: Infants ≥32 weeks gestation with isolated CDH are randomized to one of two feeding protocols. The early oral (EO) group receives oral feeds on higher respiratory support (≤5 L HFNC) without initial enteral tube placement. A nasogastric (NG) tube is placed when specific exit criteria are met. The delayed oral (DO) group receives nasogastric tube feeds initially, with oral feeds introduced once on ≤2 L HFNC. The primary outcome is safety, defined as a need for escalation of respiratory support within 6 hours of oral feeds, and adverse events including aspiration, malnutrition, and central line complications. Secondary outcomes include change in NEOs score group, enteral feeding tube use at discharge, central line duration, length of stay, and growth. A total of 24 infants will be enrolled over 24 months.

Results: This preliminary analysis includes 10 patients (5 per group). Gender, race, and ethnicity were similar between groups (Table 1). The DO group had a significantly higher mean gestational age than the EO group (38.0 ± 0.7 vs. 36.5 ± 1.6 weeks, p = 0.038). No aspiration events, central line infections, TPN-associated cholestasis, or malnutrition were reported. No infants required escalation in respiratory support due to clinical concerns following oral feeding attempts. First oral feed occurred earlier in the EO group (DOL 16 ± 8.3 vs. 19 ± 6.9, p = 0.55). Full oral feeding at discharge was achieved in 80% of EO vs. 40% of DO infants (p = 0.26). Central line duration (37.2 vs. 30.5 days, p = 0.29) and length of stay (51.0 vs. 41.8 days, p = 0.31) were longer in the EO group but not statistically significant (Table 2).

Conclusions: Preliminary findings suggest early oral feeding may be safe in this population. Ongoing enrollment will allow for evaluation of safety and efficacy, informing future multicenter trials and evidence-based feeding guidelines for infants with CDH.