|Year : 2017 | Volume
| Issue : 4 | Page : 231-235
Early enteral feeding following repair of gastroschisis is associated with shorter length of admission and better nutritional outcomes
Patrick James Thompson1, Karen Walker2, Robert Halliday2, Andrew J.A Holland3, Amit Trivedi2
1 The Grace Centre for Newborn Care, The Children's Hospital at Westmead, Westmead; Department of Neonatology, Royal North Shore Hospital, St Leonards, NSW; Faculty of Medicine, University of Sydney, Sydney, Australia
2 The Grace Centre for Newborn Care, The Children's Hospital at Westmead, Westmead, Australia
3 Department of Paediatric Surgery, The Children's Hospital at Westmead, Westmead, Australia
|Date of Web Publication||17-Oct-2017|
Patrick James Thompson
Department of Neonatology, Clinical Fellow, Level 6, Clinical Services Building, Royal North Shore Hospital, St Leonards, NSW 2065
Source of Support: None, Conflict of Interest: None
Aim: The aim of the study was to review timing and substrate of initial enteral feeding in the management of infants with gastroschisis (GS) with analysis of their relationship to nutritional outcomes and length of Neonatal Intensive Care Unit (NICU) admission. Methods: A retrospective review was conducted of consecutive admissions of infants with GS to a quaternary NICU between 2010 and 2016. Demographic, clinical data and data on nutritional status and growth were collected. Relationships between time to initiate enteral feeding and length of NICU admission, duration of parenteral nutrition (PN), and time taken to regain birth weight were assessed, as well as effect of exclusive human milk on length of NICU admission and duration of PN. Results and Conclusions: Survival in this cohort was 100%. Significant positive correlations were found between time taken to initiate enteral feeding after abdominal closure and each of the primary outcomes: length of NICU stay, duration of PN, and time taken to regain birth weight. There was no effect of exclusive human milk feeding on either duration of PN or length of NICU stay. A higher rate of exclusive human milk feeding was observed than in published literature.
Keywords: Enteral feeding, gastroschisis, neonatal, surgery
|How to cite this article:|
Thompson PJ, Walker K, Halliday R, Holland AJ, Trivedi A. Early enteral feeding following repair of gastroschisis is associated with shorter length of admission and better nutritional outcomes. J Clin Neonatol 2017;6:231-5
|How to cite this URL:|
Thompson PJ, Walker K, Halliday R, Holland AJ, Trivedi A. Early enteral feeding following repair of gastroschisis is associated with shorter length of admission and better nutritional outcomes. J Clin Neonatol [serial online] 2017 [cited 2018 May 26];6:231-5. Available from: http://www.jcnonweb.com/text.asp?2017/6/4/231/216908
| Introduction|| |
Gastroschisis (GS) is a congenital abdominal wall defect (AWD) resulting in prolapse of abdominal contents into the amniotic cavity. The defect is almost always to the right of the umbilicus, usually featuring herniation of bowel alone with no covering membrane. It is often reviewed in conjunction with other AWDs including omphalocele and triad syndrome but is uniquely different in its etiology, risk factors, management, and accompanying malformations. Unlike omphalocele, GS most commonly occurs as an isolated anomaly, but 10%–15% of cases are classified as “complex” (i.e., complicated by intestinal atresia, perforation, or necrosis). These complex cases tend to have poorer outcomes than “simple” GS  and are usually excluded from studies examining management strategies for GS.
The incidence of GS is approximately 4.5/10,000 live births in most contemporary reports, increasing reliably over the past 20 years. Risk factors include young maternal age, low socioeconomic status, and use of vasoactive drugs during pregnancy. The association of maternal smoking and cocaine use with increasing incidence of GS (and intestinal atresia) lend support to the theory of a causative vascular insult to the developing abdominal wall early in gestation, but more specific proposed causes include rupture of an umbilical cord hernia in utero, vascular disruption of the right omphalomesenteric artery, and anomalies of the right umbilical vein.
Although fatal before the availability of surgical repair ( first reported by Watkins in 1948), outcomes have improved dramatically since. Antenatal diagnosis, as early as 10-week gestation, is the rule in most cases (90% or more). Survival rates in most series are 90% or greater in developed countries but only 20%–30% in developing nations. Although most infants with GS will survive, there is a significant potential morbidity with impaired intestinal function, prolonged parenteral nutrition (PN), and lengthy Neonatal Intensive Care Unit (NICU) admission, together creating considerable financial and resource implications.
Controversies remain around timing and route of delivery, method of repair, and introduction of feeding following repair. This study sought to delineate the relationship between timing and substrate of feed introduction, and the primary nutritional outcomes of time to regain birth weight, duration of PN, and length of NICU stay in a large cohort cared for at a single major Australian neonatal surgical unit.
| Methods|| |
A retrospective review was conducted of consecutive admissions to a single quaternary Neonatal Intensive Care Unit of infants with GS between 2010 and 2016. Demographic and clinical data were collected including maternal and gestational age at delivery, birth weight, and route, timing, and substrate of feeding. The nutritional outcomes measured were duration of PN (as a proxy indicator of time to achievement of full enteral feeding) and time from birth to regain birth weight. Relationships between time to initiate enteral feeding, length of NICU admission, duration of PN, and time taken to regain birth weight were assessed, as well as the effect of exclusive human milk feeding on length of NICU admission and duration of PN. Ethics approval was obtained from the New South Wales Health Human Research Ethics Committee.
Outcome measures included time to regain birth weight, duration of PN, duration of NICU stay, mortality and complications, age, and weight at discharge. Statistical analysis of the data was performed using the Statistical Package for the Social Sciences (SPSS software 22, IBM, Armonk, New York, USA).
As the length of time from abdominal closure to the initiation of enteral feeding was not normally distributed, with some outliers, standard parametric statistical analysis was not performed. Nonparametric measure of rank correlation between the time taken to initiate enteral feeding and the primary outcomes (time to regain birth weight, duration of PN, and Length of NICU stay) was examined using a Spearman's rho (rs) correlation. A Mann–Whitney U- test was used to investigate the effect of exclusive human milk feeding on duration of PN and length of NICU stay.
| Results|| |
Sixty-nine infants with GS were identified in the study period. Nine infants with a diagnosis of complex GS were excluded from analysis. The median maternal age at birth was 23 years (range 15–36), and two infants were born from twin pregnancies. The majority of infants were female (58%), the median gestational age at delivery was 36 weeks (range 30–39), with 62% of infants born preterm (<37 weeks completed gestation). The median birth weight was 2400 g (range 1300–3860 g). Intrauterine growth restriction was identified in 28% of infants [Table 1]. Twenty-three of sixty cases were repaired using creation of a silo, with the remaining 37 cases undergoing primary closure - this decision was made at the discretion of the treating surgeon. The decision to initiate enteral feeding was made at the discretion of the treating neonatologist, in liaison with the treating surgeon - this decision required abdominal closure without suspicion of elevated intra-abdominal pressure or abdominal compartment syndrome. PN was ceased when enteral feeding of at least 150 mL/kg/day was tolerated, and the criteria for discharge from the NICU were that infants no longer required respiratory support or PN - a requirement for intragastric tube feeding was not a barrier to discharge.
Earlier enteral feeding was associated with earlier regaining of birth weight (rs= 0.376, P = 0.005). Shorter durations of both PN (rs= 0.307, P = 0.02) and length of NICU stay (rs= 0.388, P = 0.003) were also seen with earlier introduction of feeding. These results are shown in [Table 2].
The majority of infants (52%) were fed exclusively with human milk during their admission, but no significant effect of this was observed on either duration of PN (P > 0.1) or length of NICU stay (P > 0.1) (Mann–Whitney U- tests).
| Discussion|| |
This study aimed to investigate whether benefits described in the literature from early enteral feeding after repair of GS were present in this cohort, as well as examining the effect of exclusive feeding with human milk. Preterm infants who receive enteral feeding within 2 weeks of age have a more mature intestinal motility pattern than unfed age-matched infants. Low birth weight infants receiving minimal enteral feeding with PN demonstrate improved weight gain and feed tolerance and shorter duration of PN, decreased incidence of sepsis, and earlier discharge from the NICU. Late initiation of feeding in the setting of intrauterine growth restriction is associated with more cholestatic jaundice and a greater degree of postnatal growth restriction. Trophic feeding now has an established role in the NICU, enabling the infant to benefit from enteral feeds even when full nutritive milk feeding is not feasible.
Research into the optimal management of GS is hampered by a comparatively low disease incidence, nonstandardized data collection, and prolonged accrual., Use of pooled data and establishment of large databases aid in the management of neonatal surgery, with examples including the Canadian Pediatric Surgical Network  and the British Association of Paediatric Surgeons Congenital Anomalies Surveillance System. The NICU in which this study's cohort was managed uses an electronic medical record system for all clinical notes and observations and collects patient data including intravenous nutrition, feeding regimen, substrate, and weight gain, as well as hospital admission parameters, which provided access to the raw data analyzed and allowed detailed analysis of a cohort of comparable size to many similarly-focused studies in the literature. The study period was chosen due to a lack of sufficient reliable data before 2010 future analysis will have access to greater numbers as this cohort grows.
We have demonstrated moderately strong positive correlations between time taken to initiate enteral feeding following GS repair and three clinically relevant outcomes: time taken to regain birth weight, duration of PN, and length of NICU admission. Poor tolerance (actual or perceived) of feeding following abdominal surgery in infants can provide a real barrier to establish enteral feeding and prolong the requirement for nonphysiological, PN. On the other hand, prolonged PN necessitates longer central venous access, associated with increased incidence of infection and PN-associated liver disease. It was encouraging to find that earlier feeding not only resulted in better weight gain but also shorter duration of PN. It is likely that the earlier introduction of enteral feeding stimulates mucosal adaptation, enabling the attainment of full enteral feeding earlier. Increasing length of hospitalization carries significant financial and resource implications for both health-care providers and families), the average cost of care of the patient with GS being up to 84 times that of an uncomplicated birth, with a mean length of stay of 41 days. The decrease in length of stay (to a mean of 31 days) in our cohort with earlier enteral feeding was almost certainly related to the other two outcomes, given that persistent PN requirement and inadequate feeding are the most common barriers to discharge from NICU. Sharp et al. found a significant positive relationship between age at first feed and LOS, with each additional day of age at first feed producing a 1.05-day increase in LOS and a 1.06-day increase in duration of PN. In a multicenter analysis over 10 years, Singh et al. found that feeding babies within ten days of surgery significantly lowered not only LOS and duration of PN but also the incidence of sepsis. Miranda da Silva Alves et al. similarly found shorter LOS if enteral nutrition was commenced within the first 12 days of life and a 5.4% increase in LOS for each additional day of PN duration. Our data are consistent with these findings.
Aljahdali et al. divided 570 babies into 4 groups based on the timing of feed commencement after closure (0–7, 8–14, 15–21, and >21 days). They found that, for each one day's delay in commencing enteral feeding, there was an increase in PN duration by 1.55 days, LOS by 1.39 days, and risk of infectious complication by a factor of 1.39. There appeared to be a reduction in benefit if feeds were introduced within 7 days of closure - the number of infants in our study was insufficient for this level of analysis, but with extension of our cohort over time it would be a logical investigation, with the goal of identifying an optimal time to commence enteral feeding following repair of GS.
Walter-Nicolet et al. published a prospective study of a “minimal enteral feeding” (MEF) program examining the effect of early trophic feeding and a controlled grading program on GS outcomes. They compared 22 infants fed with the standardized MEF protocol with 51 historical controls and found a significant improvement in time to full enteral feeds, shorter duration of PN, and lower infection rate. Lemoine et al. also reported on a standardized protocol for feed advancement after repair of GS – they compared 16 historical controls with 16 patients on a new standardized feeding protocol, examining LOS as a primary outcome, and “sepsis incidence,” “days from starting feeds to achieving full feeds,” and “days from surgical closure to starting feeds” as secondary outcomes. Although their primary outcome measure favored the historical control group, there was a significant improvement in all three secondary outcomes with the standardized feeding protocol. A confounder in this study was the institution of a central venous catheter care and maintenance policy change initiated just before the commencement of the standardized feeding protocol.
Human milk feeding results in faster attainment of full enteral feeds by promoting intestinal adaptation and expediting the recovery of bowel function; a concept explored in a retrospective study of the percentage of human milk consumption and its effect on both “time taken to achieve full enteral feeding” and LOS in 79 North American infants with GS. There were significant decreases in both parameters for babies fed exclusive human milk (compared with nonexclusive), but a graded response to the percent consumption of human milk was not shown. In our study, there was no difference observed in either length of NICU stay or duration of PN (a surrogate for time to achieve full feeding) with exclusive human milk. A majority (52%) of our infants were fed exclusively with human milk in the NICU rates in the literature are usually in the order of 30% or less.
Limitations of this study include our sample size and its retrospective, observational nature. Given that the data were not distributed normally, the statistics used were limited to correlation, rather than enabling an examination of causality. The outcomes examined in our study (particularly duration of NICU admission and duration of PN) were interrelated. Assessing their individual effects, in a suitably designed prospective trial, is an important direction for future research.
We have demonstrated strong positive correlation between the time taken to initiate enteral feeding and each of the three clinical outcomes following GS repair: Time taken to regain birth weight, duration of PN, and length of NICU admission. This is consistent with other studies and supports an early feeding approach to postoperative management of GS. Future avenues for investigation could include subgroup analysis of time to initiation of enteral feeding, the effect of continued feeding in the face of significant (even bilious) aspirates, prospective study of a standardized feed advancement protocol, the value of exclusive human milk feeding, and the potential role of prokinetic agents.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Owen A, Marven S, Johnson P, Kurinczuk J, Spark P, Draper ES, et al.
Gastroschisis: A national cohort study to describe contemporary surgical strategies and outcomes. J Pediatr Surg 2010;45:1808-16.
Holland AJ, Walker K, Badawi N. Gastroschisis: An update. Pediatr Surg Int 2010;26:871-8.
Sharp M, Bulsara M, Gollow I, Pemberton P. Gastroschisis: Early enteral feeds may improve outcome. J Paediatr Child Health 2000;36:472-6.
Baird R, Eeson G, Safavi A, Puligandla P, Laberge JM, Skarsgard ED; Canadian Pediatric Surgery Network. Institutional practice and outcome variation in the management of congenital diaphragmatic hernia and gastroschisis in Canada: A report from the Canadian Pediatric Surgery Network. J Pediatr Surg 2011;46:801-7.
Tarca E, Ciongradi I, Aprodu SG. Birth weight, compromised bowel and sepsis are the main variables significantly influencing outcome in gastroschisis. Chirurgia (Bucur) 2015;110:151-6.
Berseth CL, Nordyke C. Enteral nutrients promote postnatal maturation of intestinal motor activity in preterm infants. Am J Physiol Gastrointest Liver Physiol 1993;264:G1046-51.
McClure RJ, Newell SJ. Randomised control trial of trophic feeding and gut motility. Arch Dis Child Fetal Neonatal Ed 1999;80:F54-58.
Okada Y, Klein N, van Saene HK, Pierro A. Small volumes of enteral feeds normalise immune function in infants receiving parenteral nutrition. J Paediatr Surg 1998;33:16-9.
Al Hazzani F. Early or delayed enteral feeding for preterm growth-restricted infants: A randomized trial. J Clin Neonatol 2012;1:181-3.
] [Full text]
Newell SJ. Enteral feeding of the micropremie. Clin Perinatol 2000;27:221-34.
Allin BS, Tse WH, Marven S, Johnson PR, Knight M. Challenges of improving the evidence base in smaller surgical specialties, as highlighted by a systematic review of gastroschisis management. PLoS One 2015;10:e0116908.
Skarsgard ED, Claydon J, Bouchard S, Kim PC, Lee SK, Laberge JM, et al
. Canadian Pediatric Surgical Network: A population-based pediatric surgery network and database for analysing surgical birth defects. The first 100 cases of gastroschisis. J Pediatr Surg 2008;43:30-4.
Singh SJ, Fraser A, Leditschke JF, Spence K, Kimble R, Dalby-Payne J, et al.
Gastroschisis: Determinants of neonatal outcome. Pediatr Surg Int 2003;19:260-5.
Lemoine JB, Smith RR, White D. Got milk? Effects of early enteral feedings in patients with gastroschisis. Adv Neonatal Care 2015;15:166-75.
Miranda da Silva Alves F, Miranda ME, de Aguiar MJ, Bouzada Viana MC. Nutritional management and postoperative prognosis of newborns submitted to primary surgical repair of gastroschisis. J Pediatr (Rio J) 2016;92:268-75.
Aljahdali A, Mohajerani N, Skarsgard ED; Canadian Pediatric Surgery Network (CAPSNet). Effect of timing of enteral feeding on outcome in gastroschisis. J Pediatr Surg 2013;48:971-6.
Walter-Nicolet E, Rousseau V, Kieffer F, Fusaro F, Bourdaud N, Oucherif S, et al.
Neonatal outcome of gastroschisis is mainly influenced by nutritional management. J Pediatr Gastroenterol Nutr 2009;48:612-7.
Kohler JA Sr., Perkins AM, Bass WT. Human milk versus formula after gastroschisis repair: Effects on time to full feeds and time to discharge. J Perinatol 2013;33:627-30.
[Table 1], [Table 2]