Nutritional management and postoperative prognosis of newborns submitted to primary surgical repair of gastroschisis

Evaluation of gastroschisis feeding protocol: A retrospective cohort study

AIM

The primary objective of this study is to determine the impact of a standardised feeding protocol for infants with gastroschisis on early enteral feeds, suck feeds, management of gastric residuals and breastfeeding at discharge. Secondary objectives were evaluation of growth, length of stay in neonatal intensive care unit (NICU), the duration of total parental nutrition (TPN), blood-culture confirmed sepsis and serum bilirubin level (SBR).

METHODS

This single-centre retrospective quality improvement project included infants admitted to a quaternary care NICU for management of gastroschisis from 2010 to 2021. The Gastroschisis feeding protocol, a standardised pathway for managing the feeding of infants with gastroschisis, was implemented in this NICU in 2016. The outcomes of infants in the pre-feeding protocol and post-feeding protocol groups were compared.

RESULTS

Of the 100 infants included in the study, 49 were in the post-feeding protocol group. The baseline characteristics of the study population did not differ statistically in both groups. In post-feeding protocol group, there was significant reduction in the time to the first enteral feed (P value <0.0001) and first suck feed (P value = 0.002). The median length of stay in the post-feeding protocol group was significantly lower by 11 days (P value = 0.001). Duration of TPN was 241 h higher in the pre-feeding protocol group (P value 0.0007).

CONCLUSIONS

Implementation of a feeding protocol in infants with gastroschisis led to earlier initiation of enteral feeds and suck feeds. There is a likelihood of reduction in the use of TPN and duration of admission in NICU.

Factors associated with cholestasis in newborns with gastroschisis

OBJECTIVE

To describe the incidence and to analyze risk factors associated with cholestasis in neonates with gastroschisis.

METHODS

This is a retrospective cohort study in a tertiary single center analyzing 181 newborns with gastroschisis between 2009 and 2020. The following risk factors associated with cholestasis were analyzed: gestational age, birth weight, type of gastroschisis, silo closure or immediate closure, days of parenteral nutrition, type of lipid emulsion, days of fasting, days to reach a full diet, days with central venous catheter, presence of infections, and outcomes.

RESULTS

Among the 176 patients evaluated, 41 (23.3%) evolved with cholestasis. In the univariate analysis, low birth weight (p=0.023), prematurity (p<0.001), lipid emulsion with medium-chain triglycerides and long-chain triglycerides (p=0.001) and death (p<0.001) were associated with cholestasis. In the multivariate analysis, patients who received lipid emulsion with fish oil instead of medium chain triglycerides/long chain triglycerides (MCT/LCT) emulsion had a lower risk of cholestasis.

CONCLUSIONS

Our study shows that lipid emulsion with fish oil is associated with a lower risk of cholestasis in neonates with gastroschisis. However, this is a retrospective study and a prospective study should be performed to confirm the results.

Bedside reduction of gastroschisis: A preliminary experience in yaounde-cameroon

Background

Gastroschisis denotes a congenital or sporadic malformation of the anterior abdominal wall, which is rarely associated with other anomalies. The mortality in African countries is still high almost 100%.

Objective

The aim was to determine the feasibility and safety of bedside reduction of gastroschisis and factors affecting the outcome in low-income setting.

Methodology

This was a retrospective, descriptive and analytic study over a period of 6 years conducted in the Pediatric Surgery Service of the Yaoundé Gyneco-Obstetric and Pediatric Hospital. Only neonates with gastroschisis seen within 6 h of life without bowel necrosis and in whom bedside reduction was attempted in the neonatology unit under sedation (with 0.5 mg/kg of diazepam intra-rectally and 0.5-1 mg of atropine intravenously) were included in this study. Ethical clearance was obtained for the Ethical Committee of the Yaoundé Gyneco-Obstetric and Pediatric Hospital and a signed consent form was required from the parents of the children prior to the procedure.

Results

Twelve neonates with a mean age of 16.8 h (0 and 24 h) and mean birth weight of 2245 g (1860-3600 g) were enrolled. The mean time to presentation at hospital was 3.5 h (2-9 h). Bedside closure was successful in 10 patients. Two patients underwent primary closure in the theatre after failure of bedside reduction due to the volume of contents of gastroschisis. Mortality rate in our study was 33.3% and the morbidity was dominated by compartment syndrome and malnutrition.

Conclusion

Bedside reduction of gastroschisis under sedation in Yaoundé seems to be way to reduce the mortality.

Gastroschisis prognostic score successfully identifies Brazilian newborns with high-risk gastroschisis

BACKGROUND

The Gastroschisis Prognostic Score (GPS) stratifies patients as high or low risk based on the visual assessment of intestinal matting, atresia, perforation, or necrosis. Despite being a simple score, its applicability to low and middle-income countries (LMICs) remains unknown. We tested the hypothesis that GPS can predict outcomes in LMICs, by assessing the prognostic value of the GPS in a middle-income country.

METHODS

This prospective study followed all newborns with gastroschisis in a Brazilian neonatal unit based in a public hospital from 2015-2019. Infants were stratified into low and high-risk cohorts based on the GPS. In addition to basic demographics, data collected included duration of parenteral nutrition (TPN), mechanical ventilation (MV), length of stay (LOS), suspicion of infection that led to the use of antibiotics, and mortality. Univariate and multivariate analyses were conducted to identify which outcomes the GPS independently predicted.

RESULTS

Sixty-one newborns with gastroschisis were treated during the study period. The mean birth weight, gestational age, and 5' Apgar score were 2258 g, 36 weeks, and 9. Twenty-four infants (39.3%) were identified as low-risk (GPS < 2) and 37 (60.7%) as high-risk (GPS > 2). The high-risk group presented with prolonged TPN use (p<0.001), MV (p<0.001), and LOS (p:0.002). GPS did not predict antibiotic therapy or mortality.

CONCLUSION

In the first study in a middle-income country, the GPS predicted several important clinical outcomes. The GPS is a reliable tool for parental counseling and resource allocation in diverse settings.

LEVEL OF EVIDENCE

II.c (cohort prospective).

Gastroschisis and late-onset neonatal sepsis in a tertiary referral center in Southeastern Brazil

OBJECTIVES

To analyze late-onset sepsis and to describe the etiological agents in newborns with gastroschisis.

METHODS

A retrospective cohort, including newborns with gastroschisis whose admissions occurred in the period between January 2012 to December 2018 in a tertiary referral center. Maternal and newborn characteristics, surgical procedures and evolution in hospitalization were verified. A bivariate analysis was performed with patients with proven late-onset neonatal sepsis and according to the simple or complex gastroschisis category, the prevalent microorganisms in positive cultures were identified, statistical tests were carried out and the significance level adopted was p < 0,05. Results are presented in proportions, averages and standard deviation or medians. The level of significance adopted was p < 0.05.

RESULTS

101 newborns were analyzed, 45 (44.5%) were confirmed late-onset sepsis. The median birth weight was 2285+498 grams, and the gestational age was 35.9 +1.74weeks. The incidence of complex gastroschisis was 17.8%, the hospitalization time was 48.2+29.67 days and mortality was 9.9%. The newborns were divided into 2 groups: Group 1: late-onset sepsis (44.6%), and Group 2: no late-onset sepsis. The presence of complex gastroschisis was a factor associated with infection (p < 0.009). Fasting time (p < 0.001), parenteral nutrition time (p < 0.001), time to achieve full diet (p < 0.001), and hospitalization stay (p < 0.001) were higher in group 2. Gram-positive were the most frequent (51.1%), followed by Gram-negative (20%), and fungi (4.4%).

CONCLUSIONS

Newborns with gastroschisis have a higher risk of evolving with late-onset sepsis, despite this study did not calculate the risk of sepsis statistically, and the main germs detected by cultures were gram-positive bacteria, specifically Staphylococcus epidermidis.

Gastroschisis annual incidence, mortality, and trends in extreme Southern Brazil

OBJECTIVE

To analyze gastroschisis annual incidence, mortality rates, and trends in the Brazilian state of Rio Grande do Sul from the year 2000 to the year 2017.

METHOD

Population-based study with the analysis of the temporal trend of gastroschisis annual incidence and mortality rates. Data were obtained from the Live Birth Information System and the Mortality Information System, with the analysis performed by polynomial regression modeling.

RESULTS

There were 2,612,532 live births, 705 hospitalizations, and 233 deaths due to gastroschisis. The annual incidence of gastroschisis was 2.69 per 10,000 live births. The annual incidence rate increased by 85% in the total period (p = 0.003), and mortality was 33% in the 2000-2017 period. Maternal age < 25 years was a risk factor for gastroschisis (p < 0.001). Children were more likely to be born weighing < 2,500 g (p < 0.001) and with a gestational age < 37 weeks (p < 0.001). The annual incidence trend was to increase, and the mortality trend was to decrease.

CONCLUSION

Similar to what has been described in several regions/countries, there was a trend showing an 85% increase in the annual incidence of gastroschisis (p = 0.003) and the mortality was 33% with a trend of decreasing (p = 0.002).

GROWTH ANALYSIS OF PRETERM NEWBORNS WITH GASTROSCHISIS DURING HOSPITALIZATION IN A NEONATAL INTENSIVE CARE UNIT

BACKGROUND

Gastroschisis, especially complex type, prematurity and low birth weight are associated with a worse clinical outcome with higher mortality, higher incidence of sepsis and catheter-related infection, cholestasis, short bowel syndrome, greater number of days to achieve full diet, longer time of parenteral nutrition and longer hospitalization time.

OBJECTIVE

To evaluate the growth of preterm newborns with gastroschisis during their hospitalization in the neonatal intensive care unit.

METHODS

Descriptive study, based on a retrospective cohort (January 2012 to December 2018), including preterm newborns (gestational age less than 37 weeks) with simple and complex gastroschisis admitted in a tertiary neonatal intensive care unit. The following parameters were analyzed: maternal age, parity, type of delivery, birth weight, gender, gestational age, nutritional adequacy, type of gastroschisis, fasting time, parenteral nutrition time, time until achieving full enteral nutrition, hospitalization time, weight gain and outcome. The results were expressed in percentage, average, and median.

RESULTS

A total of 101 newborns with gastroschisis were admitted, of which 59.4% were premature (80.7% of late preterm infants). From the maternal data, the mean age was 21.2 years and 68.3% were primiparous. Regarding childbirth: 80% were cesarean sections. From newborns: the average birth weight was 2137 g, 56.6% were female, the average gestational age was 34.8 weeks, the average weight gain was 20.8 g/day during hospitalization and 83.3% were discharged from the hospital.

CONCLUSION

The growth analysis by weight gain (grams/day) during hospitalization in the intensive care unit showed that more than 90% of the sample presented acceptable or adequate weight gain.

Influence of birthplace on gastroschisis outcomes in a state in the southeastern region of Brazil

OBJECTIVE

To characterize the influence of birthplace on outcomes of patients with gastroschisis admitted to three hospitals in a state in Brazil's southeastern region, according to condition inborn (born in a reference center) or outborn (born outside the reference center).

METHODS

Retrospective multicenter cohort study of patients with gastroschisis. The sample size utilized was of patients admitted in three hospitals with a diagnosis of gastroschisis ICD 10 Q79.3 between January 2000 to December 2018. Patients were divided into two groups, inborn and outborn. Characteristics of prenatal, perinatal and postoperative were compared using statistical tests. The level of significance adopted was P-value < 0.05.

RESULTS

In total, 144 cases of gastroschisis were investigated. The outborn patients group had higher rates of absence of antenatal diagnosis (p = 0.001), vaginal delivery (p = 0.001), longer time between birth and abdominal wall closure surgery (p = 0.001), to silo removal (p = 0.001), to first enteral feeding (p = 0.008), for weaning from mechanical ventilation (p = 0.034), used less peripherally inserted central catheter (PICC) and required more venous dissections (p = 0.001), and lower mean of serum sodium (p = 0.015). There were no differences in mortality rates and length of hospital stay between the inborn and outborn groups.

CONCLUSION

Although outborn patients with gastroschisis were less likely to have an antenatal diagnosis and were more prone to a longer time to undergo surgical and feeding procedures, and to spend more time in mechanical ventilation, these disadvantages seemed not to reflect on the death rate and the length of hospital stay of patients from this group.

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.

Differences in attitudes to feeding post repair of Gastroschisis and development of a standardized feeding protocol

Background

The purpose of this study was to examine differences in attitudes to feeding in neonates with Gastroschisis between clinical groups and to develop a standardized feeding protocol. Confusion, inconsistencies in practice and lack of evidence could be contributing to avoidable delays in the establishment of enteral feeds resulting in lengthy requirements for central venous access, dependence on total parenteral nutrition (TPN), increased risk of sepsis, TPN related cholestasis and prolongation in length of hospital stay.

Methods

A national survey of clinicians (neonatologists, neonatal intensive care nurses and paediatric surgeons), looking after neonates with gastroschisis was undertaken to determine differences in feeding practice post repair. In addition, an audit of practice in one hospital was undertaken to examine variations in practices between clinicians. A feeding protocol was then developed using inputs from surgeons and neonatologists.

Results

Gastric aspirates and residuals were typically used as indicators of feed readiness and feed tolerance; however, there was very little consistency within and between clinical groups in definitions of tolerance or intolerance of feeds and in how to initiate and progress feeds. A feeding protocol with clear definition of feed readiness and a clear pathway to progression of feeds was developed to help overcome these variations in practice with the possibility that this might reduce the length of stay (LOS) and have other secondary benefits. The protocol included early introduction of enteral feeds particularly direct breast or sucking feeds.

Conclusions

Wide differences in attitudes to feeding neonates post Gastroschsis repair exist and the need for a consistent protocolized approach was felt. The feeding protocol we developed requires a change of practice and further clinical trials are needed to evaluate its effectiveness.

A 25-year study of gastroschisis outcomes in a middle-income country

BACKGROUND

Survival of newborns with gastroschisis is significantly higher in high-income versus low and middle-income countries. We reviewed treatment and outcomes of gastroschisis in a middle-income country setting with increasing protocolized management.

METHODS

All newborns with gastroschisis treated during the period 1989-2013 at a single Brazilian academic surgical service were studied retrospectively. Protocolized diagnosis, delivery, nutrition, medical interventions, and surgical interventions were introduced in 2002. Outcomes before and after protocol introduction were studied using univariate and multivariate analysis.

RESULTS

One hundred fifty-six newborns were treated for gastroschisis: 35 (22.4%) and 121 (77.6%) before and after 2002, respectively. When compared to the earlier cohort, patients treated after 2002 had higher rates of prenatal diagnosis (90.9% vs. 60.0%, p < 0.001), delivery at a tertiary center (90.9% vs. 62.9%, p < 0.001), early closure (65.3% vs. 33.3%, p = 0.001), primary repair (55.4% vs. 31.4%, p = 0.013), monitoring of bladder pressure (62.0% vs. 2.9%, p = 0.001), PICC placement (71.1% vs. 25.7%, p < 0.001), early initiation of enteral feeding (54.5% vs. 20.0%, p < 0.001), and lower rates of electrolyte disturbances (53.7% vs. 85.7%, p = 0.001). Mortality decreased from 34.3% before 2002 to 24.8% (p = .27) after 2002 despite an increase in the complex gastroschisis rate from 11.4% to 15.7% during the same period.

CONCLUSIONS

Gastroschisis outcomes in a middle-income country can be gradually improved through targeted interventions and management protocols.

TYPE OF STUDY

Therapeutic.

LEVEL OF EVIDENCE

III.

Direct hyperbilirubinemia in newborns with gastroschisis

BACKGROUND

Patients with gastroschisis and prolonged total (or partial) parenteral nutrition (PN) commonly develop direct hyperbilirubinemia (DH).

OBJECTIVE

To quantify the prevalence and severity of DH in newborns with gastroschisis and characterize the diagnostic work-up for DH in this patient population.

DESIGN/METHODS

Retrospective chart review of patients born with gastroschisis between 2005 and 2015 for the first 6 months of life.

RESULTS

29 patients were identified with gastroschisis. Mean gestational age and birthweight were 36.4 (± 1.8) weeks and 2.5 (± 0.6) kg. 41% were treated with primary reduction versus staged closure. Peak total and direct bilirubin (DB) levels were 10.17 ± 6.21 mg/dL and 5.58 ± 3.94 mg/dL, respectively. 23 patients (79.3%) were diagnosed with DH and 78.2% underwent additional work-up for hyperbilirubinemia consisting of imaging and laboratory studies, none of which revealed a cause for DH other than the presumed PN-associated cholestasis. In all patients, DB began to decline within 1-10 days of initiation of enteral feeds.

CONCLUSION(S)

DH is common in patients with gastroschisis and is unlikely to be associated with pathology aside from PN. Additional work-up may lead to unnecessary resource utilization.

LEVELS OF EVIDENCE

Case series with no comparison group, Level IV.

The factors associated with successful early enteral feeding in gastroschisis

BACKGROUND

Gastroschisis is the most common congenital abdominal wall defect. Due to the exposure of midgut to amniotic fluid, the recovery of bowel function is often delayed. This study aimed to identify the factors associated with the successful early enteral feeding in gastroschisis and to develop further guidelines of treatment.

METHODS

A retrospective cohort study of gastroschisis babies from January 2006 to December 2015 was done. Exclusion criteria were incomplete data and death. Successful early enteral feeding was defined when full feeding was achieved within 21 days of life.

RESULTS

One hundred and five gastroschisis patients were divided into a successful early-feeding group (n = 56, 53%) and a non-successful early-feeding group (n = 49, 46%). In multivariable analysis, significant factors for successful feeding clustered by primary treatment were female (RR = 1.38, P value < 0.001), gestational age > 36 weeks (RR = 1.23, P value < 0.001), age at surgery less than 10 h (RR = 1.15, P value < 0.001), postoperative extubation time < 4 days (RR = 1.39, P value < 0.001), and age when feeding started less than 10 days (RR = 35.69, P value < 0.001).

CONCLUSION

Several factors were found to be associated with successful early enteral feeding. The modifiable factors found in this study were surgery within 10 h, early postoperative extubation within 4 days, and feeding started before 10 days of life. These will guide the management of gastroschisis to achieve successful early enteral feeding.