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Not measuring residual gastric volumes in preterm infants can increase the progression of enteral nutrition with earlier discharge from hospital
  1. Catherine M Harrison,
  2. Claire Louise Blythe
  1. Neonatology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
  1. Correspondence to Dr Catherine M Harrison, Neonatology, Leeds Teaching Hospitals NHS Trust, Leeds LS1 3EX, UK; catherine.harrison10{at}nhs.net

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Review of: Parker LA, Weaver M, Murgas Torrazza, et al. Effect of gastric residual evaluation on enteral intake in extremely preterm infants a randomised clinical trial. JAMA Pediatrics 2019;173:534–43.

Study design

Design: Single centre randomised clinical trial.

Allocation: Low risk of randomisation bias, used computer generated sequencing. Unclear risk of allocation concealment bias, not clearly described.

Blinding: Not blinded.

Study question

Setting: Level 4 neonatal unit (regional neonatal intensive care unit), USA.

Patients: Infants born at ≤32 weeks’ gestation and ≤1250 g due to be fed human milk. Babies with congenital anomalies, chromosome abnormalities or a gastro-intestinal condition were excluded. Participation stopped if stage II or greater necrotising enterocolitis (NEC) or spontaneous intestinal perforation diagnosed.

Intervention: Residuals group (74 infants) underwent prefeed gastric residual measurement and this was factored in clinical decisions using the NICU nutritional guidelines.

Comparison: No measurement of residuals (69 infants). Feeds stopped if episode of emesis or increased abdominal circumference >2 cm. Gastric content aspiration not used to verify tube placement.

Outcomes: Primary: weekly enteral intake in ml/kg for 6 weeks following delivery.

Secondary: Days until full feeds (120 mL/kg/day), growth parameters, days until discharge, feeding intolerance, stage II or greater NEC, death, and a range of other secondary outcomes addressing incidence of complications and other markers of the neonatal course.

Follow-up: Up to 6 weeks or: discharge from NICU, death or withdrawal from study due to NEC.

Main results

The no residual group showed a significantly higher mean weekly increase in milk received compared with the residual group (20.7 mL/kg/day vs 17.9 mL/kg/day, p=0.02).

In terms of secondary outcomes, the no residual group showed improved weight gain, and were discharged home up to 8 days earlier than the residual group (86.4 days to discharge residual group vs 79.1 days, no residual group). The no residual group reached full milk feeds earlier than the residual group (15.9 days vs 18.1 days).

Many secondary outcomes were similar between the two groups. Importantly there was no significant difference in the two groups for incidence of stage II or greater NEC (estimated odds 0.026 residual vs 0.058 no residual, p=0.25).

Conclusion

Not measuring residual gastric volumes in preterm infants increases the progressions of enteral nutrition and the amount of enteral nutrition received in weeks 5 and 6 with earlier discharge from hospital.

Sources of funding: This work was supported by grant R01DK088244 from the National Institute of Nursing Research.

Not measuring residual gastric volumes in preterm infants can increase the progression of enteral nutrition with earlier discharge from hospital.

Commentary

It is routine practice in many neonatal units to measure prefeed gastric aspirates which are considered as part of a decision to feed. It is an easy procedure to perform and as such this evaluation commonly occurs as proxy for feed intolerance. However, there is a variation in the literature as to what constitutes an abnormal prefeed gastric aspiration, both in volume and colour. Previous smaller studies have shown that in babies without residual evaluations performed, time to full feeds is reduced.

This study was powered to review the primary outcome on weekly enteral intake for 6 weeks after delivery, including 143 infants. No babies received formula milk minimising variation in feed tolerance seen when comparing breast milk to formula milk.

As well as omitting prefeed gastric residual evaluation, infants in the no residual group had their feeding tube position assessed by depth measurement strategies and not aspiration.

This would need to be considered in conjunction with National Patient Safety Agency guidance which recommends only pH verification and X-ray as the methods for testing satisfactory Nasogastric (NG) tube placement on initial insertion and the following insertion, checking of the position at least once a day.1 Practically, it would be a relatively simple alteration in unit practice to withdraw the aspirate needed to check for the pH and not fully aspirate the stomach. However, there are challenges when using the gastric aspirate as an indicator of NG tube placement.2

A recent Cochrane review considers whether routine monitoring of stomach contents prevents NEC and reviewed two randomised controlled trials. It concluded that it is not clear whether routine evaluation of stomach contents has any impact. They comment that stomach aspirates may be an early indicator of NEC but that routine evaluation may increase the time taken to reach full feeds.3

This paper suggests that by not monitoring residuals, feeds can be increased more quickly with higher feed volumes established by weeks 5 and 6 and overall decreased length of hospital stay. Time to full feeds is decreased, although this was not significant, but time to discharge was reduced by 8 days. The authors suggest monitoring residuals in infants should only be done when there are concerns regarding their gastrointestinal system, for example, abdominal distension, vomiting or abnormal stools.

Not monitoring gastric residuals in preterm infants in whom there are no concerns regarding the gastrointestinal system optimises amount of nutrition received, enhances weight gain and decreases length of stay.

References

Footnotes

  • Twitter @cath_harrison10

  • Contributors CLB wrote the picket paper; this was edited and revised by CMH.

  • Provenance and peer review Not commissioned; internally peer reviewed.