Effects of prone and supine positioning on gastric residuals in preterm infants: A time series with cross-over study

The Effects of Different Nursing Positions During Preterm Infants Feeding on Gastric Residual Volume and Emptying Rate: A Systematic Review and Network Meta-Analysis

BACKGROUND AND OBJECTIVES

Preterm infants need nutritional support due to their premature digestive system, undeveloped anatomy and functional limitations. Neonatal positioning in the proper position is one of the nurses' main principles that affect the residual volume. We performed our systematic review and network meta-analysis to determine the best feeding position for preterm infants in reducing gastric residual volume and increasing the rate of gastric emptying.

METHODS

We systematically searched PubMed, Cochrane, CINHAL, Scopus and Web of Science from their inception to August 2023. We included studies that assess the effect of different feeding positions for preterm infants on gastric residuals. The Cochrane risk of bias tool (ROB2) appraised the included clinical trials. Cohort studies were assessed by the NIH tool and quasi-experimental studies by the relevant items from (Downs and Black) checklist. RevMan Version 5.4 was used for analysing the pooled data. Our study included a frequentist network meta-analysis of the aggregate data to obtain network estimates for the outcomes of interest. Network meta-analysis was done using R software.

RESULTS

We included 16 studies with 1139 premature infants, comparing six preterm feeding positions. The pooled MD and 95% CI for GRV at 30 min for right lateral, prone, right anterior oblique and left lateral compared to supine position were as follows: (-12.08 [-20.09, -4.07]), (-11.14 [-18.26, -4.01]), (-9.02 [-21.66, 3.61]) and (-0.18 [-7.87, 7.5]), respectively. Moreover, the pooled MD and 95% CI for GRV at 180 min for right lateral, prone and left lateral compared to supine position were as follows: (-0.69 [-1.29, -0.09]), (-0.56 [-1.22, 0.1]) and (0.09 [-0.63, 0.81]), respectively. Nevertheless, the pooled MD and 95% CI for GRV at 120 min for right anterior oblique, prone, right lateral and left lateral compared to supine position were as follows: (-6.09 [-11.33, -0.86]), (-5.07 [-7.71, -2.43]), (-3.08 [-5.89, -0.27]) and (-0.44 [-3.41, 2.53]), respectively.

CONCLUSION

We concluded that the best nursing position after preterm infants feeding for lower gastric residuals and higher gastric emptying rate is the right lateral position after 30 and 180 min post-feeding. Also, the right anterior oblique was the best after 120 min. Although the prone position can lower the GRV better than the left lateral and supine positions, it is not advisable to use this position because it raises the SIDS risk. Our results could help healthcare professionals to provide the appropriate positioning of preterm infants.

Effect of lying position on gastric residual volume in premature infants: A systematic review

Premature infants' gastric residual volume may be affected by position. This systematic review was conducted to examine the effect of lying position on the gastric residual volume of preterm newborns fed by gastric tube. Electronic databases (PubMed, MEDLINE, MEDLINE Complete, Academic Search Ultimate, CINAHL Complete, Cochrane, and Scopus) were searched for randomized controlled experimental or quasiexperimental studies in English published between 2011 and 2022 investigating the effect of one or more lying positions on gastric residual volume in premature newborns. The PICOS strategy was used in preparing and reporting the systematic review. A total of 304 articles were retrieved, and the full texts of 12 articles were evaluated for suitability. After eliminating the excluded articles, 10 articles were included in the analysis. The quality of evidence varied, with four studies judged to have poor quality whereas the remaining six were considered to range from moderate to good in quality. Based on the results obtained from the studies, it was determined that gastric residual volume was the least in the right lateral and prone positions and more in the left lateral and supine positions compared with the other two positions, with no difference between the two latter positions. The methodological differences, such as the evaluation of different positions, the timing of positioning and the duration of maintaining in the same position, and the measurement times of gastric residual volume made it difficult to reach a definitive proof. We concluded that high-evidence studies evaluating all positions are needed.

Effects of kangaroo mother care on feeding intolerance in preterm infants

OBJECTIVE

Feeding intolerance (FI) is a common condition in preterm infants because they have an immature gastrointestinal tract. There are studies on the effects of the position on gastric residual volume (GRV) in preterm infants. Kangaroo mother care (KMC) may be an instrument for reducing FI by providing an upright position to infants. Moreover, numerous studies conducted with this therapeutic position applied by putting an infant on the mother's chest have indicated its positive effects on the infant's weight gain, growth and development, and vital signs. Therefore, this study aimed to reveal the impact of KMC on FI in preterm infants.

METHODS

The population of the study, designed as a randomized trial, consisted of 168 preterm infants [KMC: 84, Standart Care (SC): 84] hospitalized in the neonatal intensive care unit of a university hospital between June and November 2020. Infants were randomly selected and divided into two groups. After the vital signs of the infants in both groups became stable, the infants were fed in the same position. KMC was applied to the infants in the intervention group for 1 h by preparing a suitable environment after feeding. Infants in the SC group were placed in the prone position after feeding. The GRVs of the infants in both groups were recorded on the Infant Follow-up Form before the next feeding.

RESULTS

No statistically significant difference was detected between the groups upon comparing them in terms of demographic and clinical characteristics. The body temperatures and O2 saturations of the participants in the KMC group were statistically significantly higher, and their respiratory and heart rates were lower than the SC group. The transition time to full enteral feeding was statistically significantly shorter, and FI was experienced significantly less in the KMC group infants than in the SC group (p < 0.05). There was no statistically significant difference between the groups in terms of the infants' weight gain and length of hospital stay (p > 0.05).

CONCLUSION

The present study demonstrated that KMC had a positive impact on FI in preterm infants. KMC is not only a safe care model providing the earliest contact between parents and infants but also a practice whose positive effect on the functioning of the digestive system in preterm infants we can use.

'Propped and prone' positioning reduces respiratory events in spontaneously breathing preterm infants: A randomised triple crossover study

AIM

We compared effects of infant positioning and feed-rate interventions on respiratory events and oximetry parameters in spontaneously breathing preterm infants born <32 weeks gestation managed in a neonatal unit.

METHODS

A randomised triple crossover design was employed. n = 68 infants underwent three test conditions A: control (supine/flat, gravity bolus feeds), B: position intervention (propped/prone) and C: feed-rate intervention (continuous pump feeds) in randomised sequence over three consecutive days. Primary outcomes were number of events (apnoea, bradycardia and desaturation) and percentage time SpO₂  < 80% over 24 h. The secondary outcome was percentage time SpO₂  ≥ 88%. Treatment effects were estimated using linear mixed-effects models.

RESULTS

Propped/prone positioning significantly reduced events and improved percentage time SpO₂  < 80% and ≥88% compared to both other conditions (all P < 0.001). Outcomes for the feed-rate intervention were not significantly different to control.

CONCLUSIONS

Alternative infant positioning should be considered in preterm infants managed in the neonatal unit.

Nurses' and Physicians' Rationale Behind Clinical Performance and Interpretation of Routine Prefeed Gastric Aspiration in Preterm Infants: A Cross-sectional Study

This study aims at understanding the rationale behind performing prefeed gastric aspirations in preterm infants, how nurses and physicians interpret the gastric aspiration and variations between them, and illuminating potential barriers for omitting routine prefeed aspiration. Nurses and physicians from all Danish neonatal intensive care units completed a questionnaire. Of 682 participants, the majority (94%) indicated that they routinely performed prefeed aspiration, primarily to check the feeding tube placement (nurses: 88%, physicians: 46%). Nurses feared necrotizing enterocolitis when observing a large gastric residual (GR) volume (31%) and green-stained GR (63%). Fewer nurses relative to physicians had "no worries" related to large volumes (15% vs 34%) or green-stained GR (14% vs 24%, both P < .01). More nurses than physicians intended to pause enteral feeding when observing green-stained GR (31% vs 16%, P < .01) and more nurses were concerned of completely omitting routine gastric aspirations (90% vs 46%, P < .05). The rationale behind the clinical use of GR volume and color as markers of necrotizing enterocolitis and feeding intolerance differs markedly between nurses and physicians in Denmark. If routine prefeed gastric aspiration should be omitted, special focus on information about early signs of necrotizing enterocolitis and methods to check tube placement is needed.

A Randomized, Controlled Study to Investigate How Bovine Colostrum Fortification of Human Milk Affects Bowel Habits in Preterm Infants (FortiColos Study)

Background: Human milk does not meet the nutritional needs to support optimal growth of very preterm infants during the first weeks of life. Nutrient fortifiers are therefore added to human milk, though these products are suspected to increase gut dysmotility. The objective was to evaluate whether fortification with bovine colostrum (BC) improves bowel habits compared to a conventional fortifier (CF) in very preterm infants. Methods: In an unblinded, randomized study, 242 preterm infants (26−31 weeks of gestation) were randomized to receive BC (BC, Biofiber Damino, Gesten, Denmark) or CF (FM85 PreNAN, Nestlé, Vevey, Switzerland) as a fortifier. Stools (Amsterdam Stool Scale), bowel gas restlessness, stomach appearance score, volume, and frequency of gastric residuals were recorded before each meal until 35 weeks post-menstrual age. Results: As intake of fortifiers increased, stools became harder in both groups (p < 0.01) though less in BC infants (p < 0.05). The incidence of bowel gas restlessness increased with laxative treatments and days of fortification in both groups (p < 0.01), but laxatives were prescribed later in BC infants (p < 0.01). With advancing age, stomach appearance scores improved, but more so in BC infants (p < 0.01). Conclusions: Although there are limitations, a minimally processed, bioactive milk product such as BC induced similar or slightly improved bowel habits in preterm infants.

Gravity-induced loss of aeration and atelectasis development in the preterm lung: a serial sonographic assessment

OBJECTIVE

To assess the impact of gravity and time on the changes in the distribution patterns of loss of aeration and atelectasis development in very preterm infants.

STUDY DESIGN

Preterm infants less than 32 weeks gestation were included in this prospective, observational study. Infants were assessed via serial lung ultrasound (LUS) score in four lung zones, performed on days 7, 14, 21, and 28 after birth.

RESULT

Eighty-eight patients were enrolled. There was a significant main effect of gravity (P < 0.001) and time (P = 0.01) on the LUS score between gravity-dependent lungs and non-dependent lungs. Moreover, there was a significant main effect of gravity (P = 0.003) on atelectasis development between the lungs.

CONCLUSION

Gravity and time have an impact on the changes in the distribution patterns of gravity-induced lung injuries in preterm infants.

Effect of different positions on gastric residuals in preterm infants initiating full enteral feeding

BACKGROUND

This study was conducted to determine the effect of feeding in different positions on the gastric residual volume after feeding in preterm infants who initiated full enteral feeding.

METHODS

This quasi-experimental study was conducted with the hypothesis that testing the right lateral position leads to less gastric residual than left lateral position and the prone position leads to less gastric residual than the supine position. The data were collected in four stages from 35 preterm infants. Initially, the infants were positioned in supine position and were fed. After feeding, the infant rested in the supine position for 3 h. The stomach content was aspirated, and the volume of gastric residual was measured at the 60th, 120th, and 180th min after feeding. These steps are repeated in order of in the right lateral, left lateral, and prone position. Total gastric residual volume and type of enteral feeding were evaluated.

RESULTS

There was no significant difference among the positions in terms of the volume of gastric residuals in the measurements made at 60th (P = 9.552), 120th (P = .505), and 180th min (P = .430). When the amount of decrease in the gastric residual volumes was a significant difference between all measurement times in right lateral and prone positions (P < .001).

CONCLUSION

Although no significant difference was determined between the positions, the smallest residual volumes were determined in the right lateral and prone positions. The amount of decrease in residual volume was significant in right lateral and prone positions.

25 Years of Research in Human Lactation: From Discovery to Translation

Researchers have recently called for human lactation research to be conceptualized as a biological framework where maternal and infant factors impacting human milk, in terms of composition, volume and energy content are studied along with relationships to infant growth, development and health. This approach allows for the development of evidence-based interventions that are more likely to support breastfeeding and lactation in pursuit of global breastfeeding goals. Here we summarize the seminal findings of our research programme using a biological systems approach traversing breast anatomy, milk secretion, physiology of milk removal with respect to breastfeeding and expression, milk composition and infant intake, and infant gastric emptying, culminating in the exploration of relationships with infant growth, development of body composition, and health. This approach has allowed the translation of the findings with respect to education, and clinical practice. It also sets a foundation for improved study design for future investigations in human lactation.

Optimizing Early Neonatal Nutrition and Dietary Pattern in Premature Infants

Providing adequate amounts of all essential macro- and micronutrients to preterm infants during the period of extraordinarily rapid growth from 24 to 34 weeks' postmenstrual age to achieve growth as in utero is challenging yet important, since early growth restriction and suboptimal neonatal nutrition have been identified as risk factors for adverse long-term development. Along with now well-established early parenteral nutrition, this review emphasizes enteral nutrition, which should be started early and rapidly increased. To minimize the side effects of parenteral nutrition and improve outcomes, early full enteral nutrition based on expressed mothers' own milk is an important goal. Although neonatal nutrition has improved in recent decades, existing knowledge about, for example, the optimal composition and duration of parenteral nutrition, practical aspects of the transition to full enteral nutrition or the need for breast milk fortification is limited and intensively discussed. Therefore, further prospective studies on various aspects of preterm infant feeding are needed, especially with regard to the effects on long-term outcomes. This narrative review will summarize currently available and still missing evidence regarding optimal preterm infant nutrition, with emphasis on enteral nutrition and early postnatal growth, and deduce a practical approach.

The Effect of Semirecumbent and Right Lateral Positions on the Gastric Residual Volume of Mechanically Ventilated, Critically Ill Patients

BACKGROUND

Delay in stomach discharge is a challenge for patients who are tube fed and may result in serious side effects such as pneumonia and malnutrition.

PURPOSE

This study was designed to determine the respective effects of the semirecumbent (SR) supine and right lateral (RL) with a flatbed positions on the gastric residual volume (GRV) of mechanically ventilated, critically ill adult patients.

METHODS

A randomized, crossover clinical trial design was used to investigate GRV in 36 critically ill, ventilated adult patients who were hospitalized in the intensive care unit. GRV was measured at 3 hours after three consecutive feedings. GRV was first measured in all of the participants in the supine position; after which, participants were randomly assigned into one of two therapeutic positioning groups (Group A: assessment in the SR position and then the RL position; Group B: assessment in the RL position and then the SR position).

RESULTS

GRV was significantly lower in both the SR and RL positions than in the supine position. GRV in the SR and RL positions did not vary significantly. The in-group measurements for GRV did not significantly differ for any of the three positions. In Group A, GRV was significantly lower at each subsequent measurement point.

CONCLUSION/IMPLICATIONS FOR PRACTICE

Positioning patients in the RL and SR positions rather than in the supine position is an effective strategy to reduce GRV. Furthermore, placing patients in either the RL or SR position is an effective intervention to promote faster digestion and feedings.

Evaluating the Effect of a Neonatal Care Bundle for the Prevention of Intraventricular Hemorrhage in Preterm Infants

Germinal matrix intraventricular hemorrhage (IVH) remains a severe and common complication in preterm infants. A neonatal care bundle (NCB) was implemented as an in-house guideline at a tertiary neonatal intensive care unit to reduce the incidence of IVH in preterm infants. The NCB was applied either to preterm infants <1250 g birth weight or <30 weeks gestational age or both, and standardized patient positioning, nursing care, and medical procedures within the first week of life. A retrospective cohort study was performed to investigate the effect of the NCB and other known risk factors on the occurrence and severity of IVH. Data from 229 preterm infants were analyzed. The rate of IVH was 26.2% before and 27.1% after implementing the NCB. The NCB was associated neither with reducing the overall rate of IVH (odds ratio (OR) 1.02; 95% confidence interval (CI) 0.57–1.84; p = 0.94) nor with severe IVH (OR 1.0; 95% CI 0.67–1.55; p = 0.92). After adjustment for group differences and other influencing factors, amnion infection syndrome and early intubation were associated with an increased risk for IVH. An NCB focusing on patient positioning, nursing care, and medical interventions had no impact on IVH in preterm infants. Known risk factors for IVH were confirmed.

Can they stomach it? Parent and practitioner acceptability of a trial comparing gastric residual volume measurement versus no gastric residual volume in UK NNU and PICUs: a feasibility study

BACKGROUND

Routine measurement of gastric residual volume (GRV) to guide feeding in neonatal and paediatric intensive care is widespread. However, this practice is not evidence based and may cause harm. As part of a feasibility study, we explored parent and practitioner views on the acceptability of a trial comparing GRV measurement or no GRV measurement.

METHODS

A mixed-methods study involving interviews and focus groups with practitioners and interviews with parents with experience of tube feeding in neonatal and/or paediatric intensive care. A voting system recorded closed question responses during practitioner data collection, enabling the collection of quantitative and qualitative data. Data were analysed using thematic analysis and descriptive statistics.

RESULTS

We interviewed 31 parents and nine practitioners and ran five practitioner focus groups (n=42). Participants described how the research question was logical, and the intervention would not be invasive and potential benefits of not withholding the child's feeds. However, both groups held concerns about the potential risk of not measuring GRV, including delayed diagnosis of infection and gut problems, increased risk of vomiting into lungs and causing discomfort or pain. Parent's views on GRV measurement and consent decision making were influenced by their views on the importance of feeding in the ICU, their child's prognosis and associated comorbidities or complications.

CONCLUSIONS

The majority of parents and practitioners viewed the proposed trial as acceptable. Potential concerns and preferences were identified that will need careful consideration to inform the development of the proposed trial protocol and staff training.

Effects of two different positions on stress, pain and feeding tolerance of preterm infants during tube feeding

AIMS

This study aims to investigate the effects of semi-elevated right lateral and semi-elevated supine positions on feeding tolerance, stress severity and pain levels among premature infants during tube feeding.

METHODS

This was a randomized cross-over clinical trial. A total of 34 premature infants who were fed via orogastric tube were included in this study. Feeding tolerance was assessed by abdominal circumference measurements and checking gastric residuals; this assessment was single blinded. Physiological values were evaluated before, during and after tube feeding. The stress severity and pain levels of the infants were also evaluated independently by the researchers before, during and after tube feeding. A significance level of .05 was accepted for all statistical analyses.

RESULTS

There were no difference between infants' vital signs, stress and pain scores according to feeding positions before tube feeding (p > .05). By feeding positions, a statistically significant difference was found between infants' vital signs, abdominal circumference and gastric residuals of infants during tube feeding. Pain and stress levels of infants were found to be significantly higher in the semi-elevated supine position during tube feeding (p < .05).

CONCLUSIONS

Use of the semi-elevated right lateral position during tube feeding was found to have a more helpful effect in reducing stress and pain among premature infants when compared with the use of the semi-elevated supine position.

Administration of enteral nutrition in the prone position, gastric residual volume and other clinical outcomes in critically ill patients: a systematic review

This systematic review of longitudinal studies aimed to evaluate the effect of enteral feeding of critically ill adult and pediatric patients in the prone position on gastric residual volume and other clinical outcomes. A literature search was conducted in the databases PubMed, Scopus and Embase using terms related to population and intervention. Two independent reviewers analyzed the titles and abstracts, and data collection was performed using a standardized form. Discrepancies were resolved by a third reviewer. The methodological quality of the studies was evaluated considering the potential for systematic errors, and the data were qualitatively analyzed. Four studies with adult patients and one with preterm patients were included. The gastric residual volume was evaluated as the main outcome: three studies did not show differences in the gastric residual volume between the prone and supine positions (p > 0.05), while one study showed a higher gastric residual volume during enteral feeding in the prone position (27.6mL versus 10.6mL; p < 0.05), and another group observed a greater gastric residual volume in the supine position (reduction of the gastric residual volume by 23.3% in the supine position versus 43.9% in the prone position; p < 0.01). Two studies evaluated the frequency of vomiting; one study found that it was higher in the prone position (30 versus 26 episodes; p < 0.001), while the other study found no significant difference (p > 0.05). The incidence of aspiration pneumonia and death were evaluated in one study, with no difference between groups (p > 0.05). The literature on the administration of enteral feeding in the prone position in critically ill patients is sparse and of limited quality, and the results regarding gastric residual volume are contradictory. Observational studies with appropriate sample sizes should be conducted to support conclusions on the subject.

Effect of Gastric Residual Evaluation on Enteral Intake in Extremely Preterm Infants: A Randomized Clinical Trial

IMPORTANCE

Evaluating prefeed gastric residuals is considered routine care but has little supporting evidence.

OBJECTIVE

To determine the effect of omitting prefeed gastric residual evaluation on nutritional outcomes in extremely preterm infants.

DESIGN, SETTING, AND PARTICIPANTS

This single-center randomized clinical trial compared the omission of gastric residual evaluation with prefeed gastric residual evaluation. Infants were recruited from a level 4 neonatal intensive care unit and were enrolled from October 17, 2013, to October 8, 2016, and then followed up for 6 weeks after birth. Eligible participants were infants born at 32 or fewer weeks' gestation with a birth weight of 1250 g or less; they were enrolled within 72 hours after birth and within 24 hours after feeding initiation. All participants (N = 143) were included in the modified intent-to-treat analysis, which was conducted from March to July 2018.

INTERVENTIONS

The residual group underwent prefeed gastric residual evaluation; the no residual group did not. Feeding decisions were made according to nutritional guidelines, and infants received only human milk.

MAIN OUTCOMES AND MEASURES

The primary outcome was weekly enteral nutrition intake in mL/kg for 6 weeks after birth.

RESULTS

Of 143 infants, 74 (51.7%) were randomized to undergo gastric residual evaluation (residual group) and 69 (48.3%) to omitted gastric residual evaluation (no residual group). The residual group comprised an even number of male and female infants (37 [50.0%]) with a mean (SD) gestational age of 27.1 (2.4) weeks and a mean (SD) birth weight of 888.8 (206.6) grams, whereas the no residual group had more male infants (36 [52.17%]), a mean (SD) gestational age of 27 (1.2) weeks, and a mean (SD) birth weight of 915.2 (180) grams. The no residual group had feedings that advanced more quickly compared with the residual group (mean weekly increase, 20.7 mL/kg/d vs 17.9 mL/kg/d; P = .02) and consumed more feedings at weeks 5 (137.2 [95% CI, 128.6-145.8]; P = .03) and 6 (141.6 [95% CI, 133.2-150.0]; P = .03). Among the secondary outcomes, the no residual group had higher mean estimated log weights (7.01 [95% CI, 6.99-7.02] vs 6.98 [95% CI, 6.97-7.00]; P = .03), had fewer episodes of abdominal distention (0.59 [95% CI, 0.34-1.01] vs 1.79 [95% CI, 1.27-2.53]; P = .001), and were discharged 8 days earlier (4.21 [95% CI, 4.14-4.28] vs 4.28 [95% CI, 4.19-4.36]; P = .01). Odds for necrotizing enterocolitis (0.058 [95% CI, 0.018-0.190] vs 0.026 [95% CI, 0.006-0.109]), death (0.004 [95% CI, 0.0003-0.046] vs 0.012 [95% CI, 0.001-0.131]), late-onset sepsis (0.970 [95% CI, 0.67-1.40] vs 1.38 [95% CI, 0.97-1.94]), and ventilator-associated pneumonia (0.084 [95% CI, 0.033-0.214] vs 0.056 [95% CI, 0.019-0.168]) were similar between groups.

CONCLUSIONS AND RELEVANCE

Among extremely preterm infants, the omission of gastric residual evaluation increased the delivery of enteral nutrition as well as improved weight gain and led to earlier hospital discharge; these results may translate into evidence-based practice.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01863043.

[The Effects of Breast Milk Olfactory Stimulation on Physiological Responses, Oral Feeding Progression and Body Weight in Preterm Infants]

PURPOSE

This study was conducted to evaluate the effect of breast milk olfactory stimulation on physiological responses, oral feeding progression, and body weight in preterm infants.

METHODS

A repeated measures design with nonequivalent control group was used. The participants were healthy, preterm infants born at a gestational age of 28~32 weeks; 12 in the experimental group and 16 in the control group. Data were collected prospectively in the experimental group, and retrospectively in the control group, by the same methods. Breast milk olfactory stimulation was provided 12 times over 15 days. The data were analyzed using the chi-square test, Mann-Whitney U test, Wilcoxon signed rank test and linear mixed models using SPSS 19.

RESULTS

The gastric residual volume (GRV) of the experimental group was significantly less than that of the control group. The heart rate, oxygen saturation, respiration rate, transition time to oral feeding, and body weight were not significantly different between the two groups.

CONCLUSION

These findings indicate that breast milk olfactory stimulation reduces GRV and improves digestive function in preterm infants without inducing distress.

The effects of position on gastric residual volume of premature infants in NICU

Background

Nutrition cares are of the main measures to save premature infants. In this regard, proper positioning is one of the key measures that is done by nurses; still there is a paucity of studies in this field and the results of these few studies are an area of ongoing debates. In light of this, the present paper is an attempt to determine the effects of different positioning on gastric residual volume in premature infants in NICU.

Methods

A clinical trial cross-over study was carried out on premature infants in NICU. The subjects, who had inclusion criteria, were selected through convenience sampling based on inclusion criteria and randomly allocated into three groups. Gastric residual volume before and one hours after feeding was measured and recorded for three positions including right-lateral, left-lateral, and prone. The data was analyzed via SPSS-21 using descriptive statistics such as mean, standard deviation, and frequency; and inferential statistics such as Chi Squared, Kruskal Wallis test, and Friedman test.

Results

Totally, 135 infants in three groups were studied and the results showed that minimum and maximum gastric residual volumes were in prone (6.49 ± 8.25 ML) and supine (12.59 ± 11.9 ML) positions, respectively. However, Kruskal Wallis test did not show a significant relationship between the three positions under study and the mean gastric residual volume.

Conclusion

Prone position was featured with the lowest gastric residual volume and highest possibility of absorbing nutrient. Still, given the fact that no significant difference was found in the three groups, further and deeper studies are needed.

Trial registration

The project is approved by Iranian Registry of Clinical Trial with no. IRCT. 201404134736 N6.

CARE GIVEN TO NEWBORNS FED BY GASTRIC TUBE: CONCEPTS AND PRACTICES

ABSTRACT Objective: to describe the conduct related to feeding care through gastric tube in neonates hospitalized in the Neonatal Intensive Care Unit, from scientific articles published in the last five years. Method: an integrative literature review was developed in the databases: MEDLINE, LILACS, SciELO, CINAHL and BDENF. The search for the studies was carried out in August 2016, in English, Spanish and Portuguese. Results: 33 articles were analyzed. The level of evidence was classified as level IV (30%), level VI (27%), level II (15%), level III (18%), level I, V and VII with 3% each. The analytical categories were: Gastric tubes, their materials and their use in the Neonatal Intensive Care Unit, Nursing care for enteral nutrition through gastric tube in the Neonatal Intensive Care Unit, From the tube the oral route. The time to reach total enteral nutrition is lower, as is the decrease in length of hospital stay. The largest losses of milk fat are during gastroclysis at the expense of gavage. The relationship of food tolerance to dietary dosage form and volumes is not yet conclusive. Nursing stands out: in favor of the bond with the family, in the physical examination and evaluation, in the positioning, in the non-nutritive suction during the diet, in the oral stimulus, in the observation and conduct regarding the gastric residue. Conclusion: due to the heterogeneity of the data, more randomized and qualitative clinical trials are required to better support the conduct and improvement of nursing care.

Gavage Feed Volume Determines the Gastric Emptying Rate in Preterm Infants

OBJECTIVE

Feeding intolerance, manifesting as increased gastric residual, is a common finding in preterm neonates. Little is known about the regulation of gastric emptying early in life and the extent to which this plays a role in the preterm infants' feeding tolerance. The goal of this study was to evaluate clinically stable 28- to 32-week gestation neonates during the first 4 weeks of life and noninvasively determine their gastric emptying rate.

STUDY DESIGN

Ultrasound measurements of gastric milk content volume were obtained from 25 neonates immediately after, 30 and/or 60 minutes following routine gavage feeds. The content emptying rate was calculated from the gastric volume data.

RESULTS

Gastric emptying rate was not postnatal age-dependent, was significantly higher at 30 minutes, whenever compared with 60-minute postfeed and directly proportional to the feed volume. At any postnatal age, the gastric emptying rate was at least 6-fold greater, when comparing the lowest and highest average stomach content volumes.

CONCLUSIONS

The gastric emptying rate of preterm infants is content volume-dependent and unrelated to the postnatal age. Given the present findings, further investigation on the gastric residual of preterm infants receiving larger than currently administered feed volumes at the initiation of enteral nutrition, is warranted.

Gastric Residual Volumes Versus Abdominal Girth Measurement in Assessment of Feed Tolerance in Preterm Neonates: A Randomized Controlled Trial

BACKGROUND

Preterm neonates often have feed intolerance that needs to be differentiated from necrotizing enterocolitis. Gastric residual volumes (GRV) are used to assess feed tolerance but with little scientific basis.

PURPOSE

To compare prefeed aspiration for GRV and prefeed measurement of abdominal girth (AG) in the time taken to reach full feeds in preterm infants.

METHODS

This was a randomized controlled trial. Infants with a gestational age of 27 to 37 weeks and birth weight of 750 to 2000 g, who required gavage feeds for at least 48 hours, were included. Infants were randomized into 2 groups: infants in the AG group had only prefeed AG measured. Those in the GRV group had prefeed gastric aspiration obtained for the assessment of GRV. The primary outcome was time to reach full enteral feeds at 150 mL/kg/d, tolerated for at least 24 hours. Secondary outcomes were duration of hospital stay, need for parenteral nutrition, episodes of feed intolerance, number of feeds withheld, and sepsis.

RESULTS

Infants in the AG group reached full feeds earlier than infants in the GRV group (6 vs 9.5 days; P = .04). No significant differences were found between the 2 groups with regard to secondary outcomes.

IMPLICATIONS FOR PRACTICE

Our research suggests that measurement of AG without assessment of GRV enables preterm neonates to reach full feeds faster than checking for GRV.

IMPLICATIONS FOR RESEARCH

Abdominal girth measurement as a marker for feed tolerance needs to be studied in infants less than 750 g and less than 26 weeks of gestation.

Does the Post-Feeding Position Affect Gastric Residue in Preterm Infants?

BACKGROUND

Body position affects the gastric emptying rate and hence the amount of gastric residue.

OBJECTIVE

This study aims to analyze the effect of the post-feeding position of preterm infants on gastric residue.

MATERIALS AND METHODS

This experimental study was conducted in the neonatal intensive care unit (NICU) of a university hospital (İnönü University Turgut Özal Medical Center) in Eastern Turkey. The study included 40 preterm infants weighing less than 2,000 g, who were fed orogastrically. The preterm infants were sequentially placed in four positions and were fed before each change of position. The infants were sequentially placed in the right lateral, left lateral, supine, and prone positions; their gastric residues were measured with a nasogastric tube. The gastric residue was recorded in percentages at 30, 60, 120, and 180 minutes. Ethical principles were applied in all phases of the study.

RESULTS

The lowest mean gastric residue level was observed in the right lateral position at 30 minutes (58.16 ± 12.71%) and 60 minutes (33.97 ± 15.00%). The prone position showed the lowest mean gastric residue level (1.74 ± 1.08%), followed by the right lateral (3.06 ± 1.97%), supine (3.53 ± 2.18%), and left lateral position (5.14 ± 1.85%) at 120 minutes. The final measurements were taken at 180 minutes with the right lateral position showing the lowest mean gastric residue level (0.38 ± 0.34%).

CONCLUSION

The premature infants had similar lower levels of gastric residue in the right lateral and prone positions and higher levels of gastric residue in left lateral and supine positions. The gastric emptying rate was found to be highest in the right lateral position at 30, 60, and 180 minutes and in the prone position at 120 minutes.

Importance of physiotherapy/nursing multidisciplinary integration about update newborn position in the neonatal intensive care unit

AbstractIntroduction The high-risk newborns may require long periods of hospitalization until they reach clinical stability for hospital discharge. Avoiding babies to be in only one body position may be an effective way to cause respiratory and neuro-psycho-motor benefits, comfort and preventing pressure ulcers.Objectives This study investigated the impact of physiotherapy/nursing integration in update on body positioning of the newborn in the Neonatal Intensive Care Unit.Methods A questionnaire was administered to nurses and nursing technicians of the neonatal unit of Maternity School of UFRJ and nurses of the Advanced Course in Neonatal Nursing from the same institution. Two classes were taught by the physical therapist of the sector and the questions answered before and after these lessons. It was also a brief characterization of professional participants of the study. We used the Student's t test to compare the correct answers before (PRE) and after (POST) the classes, considering p < 0.05.Results There was a significant increase in the degree of knowledge of nurses and nursing technicians when compared the responses before (nurses: 68.8%; technicians: 70.1%) and after classes (nurses: 78.4 %; technicians: 88.9%). The nurses were less than five years of graduated (45%) and little time of professional experience in neonatology (60%). Forty-seven percent of technicians had less than five years of training and 82% had less than 10 years of experience.Conclusion The use of training by the nursing staff was significant, showing the importance of multidisciplinary approach and the integration of knowledge in the search for a humanized and effective care.

Prone positioning decreases cardiac output and increases systemic vascular resistance in neonates

OBJECTIVE

To evaluate the cardiovascular response to short-term prone positioning in neonates.

STUDY DESIGN

In this prospective study, we continuously monitored heart rate (HR), stroke volume (SV) and cardiac output (CO) by electrical velocimetry in hemodynamically stable neonates in each of the following positions for 10 min: supine, prone and back-to-supine position. Skin blood flow (SBF) was also continuously assessed on the forehead or foot using Laser Doppler technology. Systemic vascular resistance (SVR) index was calculated as mean blood pressure (BP)/CO. Data were analyzed using repeated measures analysis of variance.

RESULTS

Thirty neonates (gestational age: 35±4 weeks; postmenstrual age: 36±3 weeks) were enrolled. HR did not change in response to positioning. However, in prone position, SV, CO and SBF decreased and SVR index increased from 1.5±0.3 to 1.3±0.3 ml kg(-1) (mean ±s.d., P<0.01), 206±44 to 180±41 ml kg(-1) min(-1) (P<0.01), 0.54±0.30 to 0.44±0.29 perfusion units (P<0.01) and 0.25±0.06 to 0.30±0.07 mm Hg ml(-1) kg(-1) min(-1) (P<0.01), respectively. After placing the infants back-to-supine position, SV, CO, SBF and SVR index returned to baseline. The above pattern of cardiovascular changes was consistent in vast majority of the studied neonates.

CONCLUSIONS

Short-term prone positioning is associated with decreased SV, CO and SBF and increased calculated SVR index.

Influences of breast milk composition on gastric emptying in preterm infants

OBJECTIVES

The aim of the present study was to determine whether specific biochemical and energy concentrations influence gastric emptying of unfortified and fortified mother's own milk (MOM) in stable preterm infants, and whether gastric emptying differs between feeds of unfortified MOM and feeds fortified with S-26 or FM 85 human milk fortifier (HMF) when infants are fed the same volume under similar conditions. Influences of infant gestation, age, and weight, and feed characteristics were also explored.

METHODS

Stomach volumes of 25 paired unfortified and fortified MOM feeds were monitored prefeed and postfeed delivery and at 30-minute intervals thereafter. For each feed, MOM samples were analyzed to determine concentrations of total protein, casein, whey, carbohydrate, lactose, fat, and energy. Fortified feed compositions were calculated by adding fortifier biochemical and energy concentrations to unfortified MOM concentrations. Ultrasound images were used to calculate infant stomach volumes. Statistical comparisons were made of paired stomach volume measurements.

RESULTS

Higher feed concentrations of casein were associated with faster gastric emptying during feed delivery (P = 0.007). When compared with unfortified MOM, S-26 fortified feeds emptied similarly, whereas FM 85 fortified feeds emptied more slowly both during feed delivery and during the postprandial period (P = 0.002, <0.001, respectively). Gastric emptying was slower for 2-hourly feeds compared with that for 3-hourly feeds (P = 0.003) and in supine position compared with that in prone (P = 0.001).

CONCLUSIONS

Breast milk composition influences gastric emptying in stable preterm infants, with feeds of higher casein concentration emptying faster during feeding than otherwise equivalent feeds, and FM 85 fortified MOM emptying more slowly than unfortified MOM.

Guidelines for feeding very low birth weight infants

Despite the fact that feeding a very low birth weight (VLBW) neonate is a fundamental and inevitable part of its management, this is a field which is beset with controversies. Optimal nutrition improves growth and neurological outcomes, and reduces the incidence of sepsis and possibly even retinopathy of prematurity. There is a great deal of heterogeneity of practice among neonatologists and pediatricians regarding feeding VLBW infants. A working group on feeding guidelines for VLBW infants was constituted in McMaster University, Canada. The group listed a number of important questions that had to be answered with respect to feeding VLBW infants, systematically reviewed the literature, critically appraised the level of evidence, and generated a comprehensive set of guidelines. These guidelines form the basis of this state-of-art review. The review touches upon trophic feeding, nutritional feeding, fortification, feeding in special circumstances, assessment of feed tolerance, and management of gastric residuals, gastro-esophageal reflux, and glycerin enemas.

Aspiration and evaluation of gastric residuals in the neonatal intensive care unit: state of the science

The routine aspiration of gastric residuals (GR) is considered standard care for critically ill infants in the neonatal intensive care unit (NICU). Unfortunately, scant information exists regarding the risks and benefits associated with this common procedure. This article provides the state of the science regarding what is known about the routine aspiration and evaluation of GRs in the NICU focusing on the following issues: (1) the use of GRs for verification of feeding tube placement, (2) GRs as an indicator of gastric contents, (3) GRs as an indicator of feeding intolerance or necrotizing enterocolitis, (4) the association between GR volume and ventilator-associated pneumonia, (5) whether GRs should be discarded or refed, (6) the definition of an abnormal GR, and (7) the potential risks associated with aspiration and evaluation of GRs. Recommendations for further research and practice guidelines are also provided.

Repeatability of gastric volume measurements and intragastric content using ultrasound in preterm infants

OBJECTIVES

The aim of the present study was to determine whether serial gastric volumes and intragastric curding are repeatable within individual preterm infants when given sequential feeds of the same volume and composition. Infant and feeding characteristics that may influence differences in measured gastric volumes, echogenicity, and intragastric curding were also explored.

METHODS

Ultrasound images were used to calculate gastric volumes and to rate echogenicity and intragastric curding for 20 infants. A total of 29 paired feeds of the same volume and composition were monitored prefeed and postfeed and at 30-minute intervals thereafter. Statistical comparisons of paired gastric volume measurements and agreement between echogenicity and curding ratings were made for each time point. Analyses of factors that influence discrepancies between volume measurements and between curding ratings were performed.

RESULTS

Paired gastric volume measurements were repeatable (intraclass correlation coefficient [ICC] = 0.971, 0.938 < ICC < 0.987). Most (75%) discrepancies were <2 mL and increased over time, although volume differences were small. Overall moderate levels of consistency were observed for ratings of echogenicity (κ = 0.44), and curd presence (κ ≤ 0.65), density (κ = 0.41), and volume (κ = 0.47). Gastric emptying during feed delivery is influenced with infant positioning, fortification of breast milk, and feeding frequency.

CONCLUSIONS

For preterm infants serial gastric volumes are repeatable and ratings of intragastric echogenicity and curding are moderately consistent when fed milk of the same volume and composition. Ultrasound has the potential to further explore factors that influence gastric emptying in the preterm infant.