The factors associated with successful early enteral feeding in gastroschisis

Bilateral Exchange: Enteral Nutrition Clinical Decision Making in Pediatric Surgery Patients

INTRODUCTION

Evidence-based medicine guides clinical decision-making; however, promoting enteral nutrition has historically followed a dogmatic approach in which patients graduate from clear liquids to full liquids to a regular diet after return of bowel function. Enhanced recovery after surgery has demonstrated that early enteral nutrition initiation is associated with shorter hospital stays. We aimed to understand postoperative pediatric nutrition practices in Kenya and the United States.

METHODS

We completed a prospective observational study of pediatric surgery fellows during clinical rounds in a pediatric referral center in Kenya (S4A) and one in the United States (Riley). Fellow-patient interactions were observed from postoperative day one to discharge or postoperative day 30, whichever happened first. Patient demographic, operative information, and daily observations including nutritional status were collected via REDCap.

RESULTS

We included 75 patients with 41 (54.7%) from Kenya; patients in Kenya were younger with 40% of patients in Kenya presenting as neonates. Median time to initiation and full enteral nutrition was shorter for the patients at Riley when compared to their counterparts at S4A. In the neonatal subgroup, patients at S4A initiated enteral nutrition sooner, but their hospital length of stays were not significantly different.

CONCLUSIONS

Studying current nutrition practices may guide early enteral nutrition protocols. Implementing these protocols, particularly in a setting where enteral nutrition alternatives are minimal, may provide evidence of success and overrule dogmatic nutrition advancement. Studying implementation of these protocols in resource-constrained areas, where patient length of stay is often related to socioeconomic factors, may identify additional benefits to patients.

Use of breast milk in infants with uncomplicated gastroschisis: A retrospective cohort study

BACKGROUND

Infants with gastroschisis often experience slow return of bowel function following closure. The purpose of this study was to determine whether exclusive breast milk is associated with decreased time to enteral autonomy.

METHODS

We conducted a retrospective cohort study of infants with uncomplicated gastroschisis from a tertiary pediatric hospital. The primary outcome was enteral autonomy, defined as days from initiating enteral feeds to stopping parenteral nutrition. Secondary outcomes included days of parenteral nutrition, length of stay, positive culture, necrotizing enterocolitis, cholestasis, additional surgery, readmission, and mortality.

RESULTS

We identified 100 infants with gastroschisis treated from 2005 to 2019. Twenty-five were excluded due to gestational age <32 weeks, birth weight <1500 g, or gastroschisis-associated complications (e.g., intestinal atresia). Seventy-five were included in the analysis. Mean gestational age was 36 weeks, 48% were female, and all were diagnosed antenatally. Sixty-five infants (87%) received exclusive maternal (n = 64) or donor (n = 1) breast milk, while 10 others (13%) were fed formula for 1-16 days (mean 7 days). Two infants received formula only. Demographics and gastroschisis prognostic scores were similar between groups. Infants who were given breast milk exclusively demonstrated decreased time to enteral autonomy (median 18 versus 25 days, p = 0.023) and shorter duration of parenteral nutrition (median 20 versus 26 days, p = 0.037).

CONCLUSION

Exclusive breast milk may be associated with improved outcomes among infants with gastroschisis. Further research is needed to evaluate the economic impact of this association and explore possible confounders. These efforts may expand the role of donor breast milk for these patients.

The effect of standardized feeding protocol on early outcome following gastroschisis repair: A systematic review and meta-analysis

BACKGROUND

Improved post-operative outcomes following gastroschisis repair are attributed to advancement in perioperative and post-operative care and early enteral feeding. This study evaluates the role of standardized postoperative feeding protocols in gastroschisis.

STUDY DESIGN

A systematic review and meta-analysis of studies published from January 2000 to April 2019 in MEDLINE, EMBASE, Cochrane Library databases and Google Scholar was conducted. Primary outcomes were duration to full enteral feeding and cessation of parenteral nutrition. Secondary outcomes included days to first enteral feeding, length of stay, compliance, complication and mortality rates. Meta-analysis was done using the RevMan Analysis Statistical Package in Review Manager (Version 5.3) using a random effects model and reported as pooled Risk Ratio and Mean Difference. p-value < 0.05 was considered statistically significant.

RESULTS

Eight observational cohort studies were identified and their data analyzed. Significant heterogeneity was noted for some outcomes. Standardized feeding protocols resulted in fewer days to first enteral feeding by 3.19 days (95% CI: -4.73, -1.66, p < 0.0001) than non-protocolized feeding, less complication rates, reduced mortality and better compliance to care. The duration of parenteral nutrition and time to full enteral feeding were not significantly affected.

CONCLUSION

Protocolized feeding post-gastroschisis repair is associated with early initiation of enteral feeding. There is a likelihood of reduced rates of sepsis; shorter duration of parenteral nutrition, length of hospital stay and time to full enteral feeding. However, the latter trends are not statistically significant and will require further studies best accomplished with a prospective randomized trial or more cohort studies.

Estimating Length of Stay for Simple Gastroschisis

BACKGROUND

Length of stay (LOS) is an important measure of quality; however, estimating LOS for rare populations such as gastroschisis is problematic. Our objective was to identify explanatory variables for LOS and build a model to estimate LOS in neonates with simple gastroschisis.

METHODS

In 73 neonates with simple gastroschisis (47% female, 67% White), statistical correlations for 31 potential explanatory variables for LOS were evaluated using multivariate linear regression. Poisson regression was used to estimate LOS in predetermined subpopulations, and a life table model was developed to estimate LOS for simple gastroschisis.

RESULTS

Female sex (-2.4 d), "time to silo placement" (0.9 d), total parenteral nutrition days (0.6 d), need for any nasogastric feedings (11.4 d) and at discharge (-7 d), "feeding tolerance" (0.4 d), days to first postoperative stool (-0.3 d), and human milk exposure (-3.4 d) associated with LOS in simple gastroschisis. Estimated LOS for preterm neonates was longer than term infants (5.4 versus 4.6 wk) but similar for estimates based on sex and race. Based on these associations, we estimate that >50% of neonates with simple gastroschisis will be discharged by hospital day 35.

CONCLUSIONS

We identified several associations that explained variations in LOS and developed a novel model to estimate LOS in simple gastroschisis, which may be applied to other rare populations.