Novel PIONEER© Protocol: RCT

Survival rates after neonatal ICU (NICU) care are increasing along with the prevalence of Disorders of Deglutition (DD) among these survivors. DD includes impairments in eating, dysfunctional swallowing, and aerodigestive symptoms which lead to chronic nutritional-, growth- and neurodevelopmental issues. Early, effective, and simple crib-side diagnostic methods and therapies that normalize feeding difficulties during critical development periods are needed to avoid reliance on chronic nasogastric (NG) or gastrostomy tube (g-tube) feeding. These critical diagnostic and rehabilitative challenges are addressed through a randomized controlled trial (RCT) to improve aerodigestive and neurodevelopmental milestones in infants at risk for g-tube use, ultimately reducing public health burden throughout the child's life, which is the long-term goal.

The overarching aim is to implement the Parent-Implemented Oral Nutrition, Eating- and Esophageal rhythms Reintegration (PIONEER) program initiatives to examine the Jadcherla hypothesis. The Jadcherla Hypothesis states that engaging the enteric and central nervous system reflexes early, persistently, and safely in tube-fed infants will result in consistent programmed activation of the deglutition process, swallowing-airway interactions, peristaltic reflexes, and autonomic regulation that will advance neuroplasticity, learning and memory.

The central hypothesis is that the activatable aerodigestive reflex mechanisms are vital in managing oral eating skills, and the independent feeding outcomes (i.e., without a G-tube) depend on intervention strategies.

The rationale is that identifying successful outcomes that are scientifically driven will lay the foundation for scalable protocols. In this RCT, the effect of Parent Implemented Oral Nutrition, Eating, Esophageal reflexes Reintegration (PIONEER©) protocol on clinical and mechanistic outcomes will be examined. Therefore, the impact of the PIONEER© protocol will be tested against the standard of care by completing two specific aims: 1) Compare the efficacy of the randomized intervention by examining the hypothesis that the PIONEER© approach is more effective at achieving the primary outcome of successful oral feeding without requiring a G-tube at NICU discharge. 2) Determine and compare the longitudinal pathophysiological mechanisms in assessing the superiority in achieving the primary outcome by testing the hypothesis that infants who follow the PIONEER© protocol will have more effective mechanisms for restoring and adapting their aerodigestive reflexes.

High-resolution manometry will be used to identify differences between the two study arms concerning the sensory-motor characteristics of aerodigestive reflexes.Completion of the proposed aims will provide opportunities for scalable and generalizable approaches to improve feeding safety and efficiency, while helping infants achieve essential developmental milestones and reducing the socioeconomic burden.

RELEVANCE: This proposal addresses a critical gap for infants who require chronic tube feeding. Completing the proposed aims will result in paradigm shifting methods to optimize oral intake while decreasing the duration of chronic NG tube feeding or preventing g-tube feeding. New evidence-based standardized guidelines will emerge from this study that have the potential for scalability, improving infant feeding-intake methods, growth, and maturation, thereby, alleviating chronic eating difficulties, delayed neurodevelopmental consequences, and public health burden.

Inclusion criteria

• Nasogastric tube fed infants referred for diagnostic manometry and Gastrostomy tube planning evaluations.
• Physiologically stable convalescing infants on full enteral feeds at greater than or equal to 37.0 weeks and less than 46 weeks postmenstrual age.
• Presence of aerodigestive reflexes on diagnostic manometry.

Exclusion criteria

• Potentially lethal congenital or chromosomal anomalies
• Craniofacial defects (cleft lip or palate)
• History of GI surgery, ENT surgery, or neurosurgery
• Need for supplemental respiratory support of >2 LPM