Effective Tube Weaning and Predictive Clinical Characteristics of NICU Patients With Feeding Dysfunction

Clinical Outcomes of Neonatal Intensive Care Unit Graduates with Bridled Nasogastric Feeding Tubes

OBJECTIVE

 The aim of this study was to describe clinical outcomes of bridled nasogastric tube (NGT) program implementation for infants requiring assisted home feeding (AHF) to discharge from the neonatal intensive care unit (NICU).

STUDY DESIGN

 This was a descriptive prospective analysis of a pilot cohort of infants after implementation of a bridled NGT AHF program to facilitate discharge from level III and IV NICUs from March 2019 to October 2020.

RESULTS

 Of 29 attempts in infants, 22 infants were discharged with bridled NGTs over 18 months. Bridle placement was unsuccessful in three patients, and four bridles were removed before discharge. Bridle use ranged from 7 to 125 days, with a median duration of 37 days. Dislodgement rate was 0.69 per 100 days. Seventeen infants (77%) achieved full oral feeds, while five (23%) discharged with bridled NGTs later converted to gastrostomy tubes.

CONCLUSION

 Implementation of a bridled NGT program is feasible for level III and IV NICUs to facilitate discharging infants who require feeding support to transition home.

KEY POINTS

· Bridled NGT use after NICU is typically 1 month.. · Infants have low bridle NGT dislodgement.. · Most bridled NGT NICU grads attain full oral feeds..

Method of home tube feeding and 2-3-year neurodevelopmental outcome

OBJECTIVE

To describe the Bayley Scales of Infant Development 3rd Edition (Bayley-III) of infants discharged home receiving tube feeds.

STUDY DESIGN

Retrospective review of infants discharged with nasogastric or gastrostomy tube feeds and completed a Bayley-III assessment at 2-3-years of age through a neonatal follow-up program. Results were reported using descriptive statistics.

RESULTS

Of infants discharged with nasogastric feeds, median Bayley-III scores were in the low-average to average range, and full oral feeds were achieved in 75%. Of infants discharged with gastrostomy tube feeds, median Bayley-III scores were in the extremely low range, and full oral feeds were achieved in 36%. Our data set did not demonstrate a distinct patient demographic that correlated to the type of feeding tube at discharge.

CONCLUSION

Neurodevelopmental outcome at 2-3 years does not appear to be negatively impacted by the decision to discharge an infant from the NICU with home NG feedings.

Feeding dysfunction in NICU patients with cramped synchronized movements

Patients admitted to the neonatal intensive care unit (NICU) have higher association for neurodevelopment deficits, specifically cerebral palsy (CP). We identified patients with risk for CP using abnormal Pretchl's General Movement Assessment (GMA) and sub-category of cramped synchronized movements (CSM) and reported their feeding outcomes at discharge. Over 75 % of these patients required either nasogastric (NGT) or gastrostomy tube (GT) at discharge. Of these, 57 % weaned off their NGT or GT at home and 43 % of patients still needed a GT one year after discharge. Of those that could not wean off their NGT or GT, these patients had longer hospital stay, took lower percentage by mouth, and an older post-menstrual age at discharge. We did not find a difference in NGT or GT use between patients with IVH, ELBW, nor between their birthweight or gestation age at birth. This study provides further clinical characteristics in NICU patients who have higher risk of CP, and supports the need for skilled feeding therapy and resources both during and after NICU admission.

Remote monitoring for neonates requiring continued nasogastric tube feeding: implementation, patient characteristics, and early outcomes

OBJECTIVE

Our neonatal intensive care unit utilizes remote patient monitoring to facilitate hospital discharge with nasogastric tube (NGT) feeds. Program implementation, patient characteristics, and initial outcomes are described.

STUDY DESIGN

Data was collected prospectively in this implementation study. Descriptive statistics define weight gain, number of NGT feed days, number of days on monitoring, and physician time spent. Patient characteristics, readmissions, and implementation details are described.

RESULTS

One-hundred and four babies consented to and completed data collection. Average weight gain on monitoring was 31.4 g/day (SD 10.2). Eighty-nine babies (85.6%) achieved full oral feeds while on the program, requiring a median 5 NGT feed days (IQR 2-13) and a median 15 days on monitoring (IQR 11-27). Average physician time spent was 9.1 min per day (SD 3.7). Six babies (5.8%) had unscheduled readmissions while on the program.

CONCLUSION

Remote monitoring programs can facilitate discharge for babies with continued NGT needs.

Characteristics and Outcomes of Children Discharged With Nasoenteral Feeding Tubes

OBJECTIVES

To describe the characteristics and outcomes of children discharged from the hospital with new nasoenteral tube (NET) use after acute hospitalization.

METHODS

Retrospective cohort study using multistate Medicaid data of children <18 years old with a claim for tube feeding supplies within 30 days after discharge from a nonbirth hospitalization between 2016 and 2019. Children with a gastrostomy tube (GT) or requiring home NET use in the 90 days before admission were excluded. Outcomes included patient characteristics and associated diagnoses, 30-day emergency department (ED-only) return visits and readmissions, and subsequent GT placement.

RESULTS

We identified 1815 index hospitalizations; 77.8% were patients ≤5 years of age and 81.7% had a complex chronic condition. The most common primary diagnoses associated with index hospitalization were failure to thrive (11%), malnutrition (6.8%), and acute bronchiolitis (5.9%). Thirty-day revisits were common (49%), with 26.4% experiencing an ED-only return and 30.9% hospital readmission. Revisits with a primary diagnosis code for tube displacement/dysfunction (10.7%) or pneumonia/pneumonitis (0.3%) occurred less frequently. A minority (16.9%) of patients progressed to GT placement within 6 months, 22.3% by 1 year.

CONCLUSIONS

Children with a variety of acute and chronic conditions are discharged from the hospital with NET feeding. All-cause 30-day revisits are common, though revisits coded for specific tube-related complications occurred less frequently. A majority of patients do not progress to GT within a year. Home NET feeding may be useful for facilitating discharge among patients unable to meet their oral nutrition goals but should be weighed against the high revisit rate.

Partial Enteral Discharge Programs for High-risk Infants

Premature infants or infants born with complex medical problems are at increased risk of having delayed or dysfunctional oral feeding ability. These patients typically require assisted enteral nutrition in the form of a nasogastric tube (NGT) during their NICU hospitalization. Historically, once these infants overcame their initial reason(s) for admission, they were discharged from the NICU only after achieving full oral feedings or placement of a gastrostomy tube. Recent programs show that these infants can be successfully discharged from the hospital with partial NGT or gastrostomy tube feedings with the assistance of targeted predischarge education and outpatient support. Caregiver opinions have also been reported as satisfactory or higher with this approach. In this review, we discuss the current literature and outcomes in infants who are discharged with an NGT and provide evidence for safe practices, both during the NICU hospitalization, as well as in the outpatient setting.

Discharging Medically Complex Infants with Supplemental Nasogastric Tube Feeds: Impact on Neonatal Intensive Care Unit Length of Stay and Prevention of Gastrostomy Tubes

OBJECTIVE

The aim of this study is to evaluate the feasibility, safety, and efficacy of discharge with supplemental nasogastric tube (NGT) feeds in medically complex infants.

STUDY DESIGN

Cohort study of 400 infants enrolled in the Transitional Medical Home (TMH) program at Duke University Level IV neonatal intensive care unit from January 2013 to 2017.

RESULTS

Among 400 infants enrolled in the TMH, 57 infants were discharged with an NGT. A total of 45 infants with a variety of diagnoses and comorbidities were included in final analysis. Among 45 infants, 5 obtained a gastrostomy tube (GT) postdischarge. Median (25-75th percentile) length of use of NGT in 40 infants was 12 days (4-37). Excluding four outliers who used NGT for ≥140 days, the median length of use was 8 days (3-24). This extrapolates to a median of 288 hospital days saved for the remaining 36 infants. There were only three emergency room visits related to parental concern for incorrect NGT placement. There was no statistically significant difference in percent oral feeding predischarge or growth in first month postdischarge between infants who orally fed versus those who obtained GTs.

CONCLUSION

Discharge with supplemental NGT feeds is safe and feasible utilizing a standardized protocol and close postdischarge follow-up. This practice can decrease length of stay and prevent need for GT.

KEY POINTS

· Discharge with nasogastric tube (NGT) supplementation is safe.. · Discharge with NGT supplementation decreases cost.. · Discharge with NGT can decrease neonatal intensive care unit length of stay.. · Medical home model facilitates safe discharge..

Actual and Potential Impact of a Home Nasogastric Tube Feeding Program for Infants Whose Neonatal Intensive Care Unit Discharge Is Affected by Delayed Oral Feedings

OBJECTIVE

To compare healthcare use and parent health-related quality of life (HRQL) in 3 groups of infants whose neonatal intensive care unit (NICU) discharge was delayed by oral feedings.

STUDY DESIGN

This was a prospective, single-center cohort of infants in the NICU from September 2018 to March 2020. After enrollment, weekly chart review determined eligibility for home nasogastric (NG) feeds based on predetermined criteria. Actual discharge feeding decisions were at clinical discretion. At 3 months' postdischarge, we compared acute healthcare use and parental HRQL, measured by the PedsQL Family Impact Module, among infants who were NG eligible but discharged with all oral feeds, discharged with NG feeds, and discharged with gastrostomy (G) tubes. We calculated NICU days saved by home NG discharges.

RESULTS

Among 180 infants, 80 were orally fed, 35 used NG, and 65 used G tubes. Compared with infants who had NG-tube feedings, infants who had G-tube feedings had more gastrointestinal or tube-related readmissions and emergency encounters (unadjusted OR 3.97, 95% CI 1.3-12.7, P = .02), and orally-fed infants showed no difference in use (unadjusted OR 0.41, 95% CI 0.1-1.7, P = .225). Multivariable adjustment did not change these comparisons. Parent HRQL at 3 months did not differ between groups. Infants discharged home with NG tubes saved 1574 NICU days.

CONCLUSIONS

NICU discharge with NG feeds is associated with reduced NICU stay without increased postdischarge healthcare use or decreased parent HRQL, whereas G-tube feeding was associated with increased postdischarge healthcare use.