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Branagan A, Murphy C, O'Sullivan A, Bodnarova I, Feyereislova S, Berka I, Miletin J, Stranak Z. Influence of gastric residual assessment in preterm neonates on time to achieve enteral feeding (the GRASS trial)-Multi-centre, assessor-blinded randomised clinical trial. Eur J Pediatr 2024; 183:2325-2332. [PMID: 38427039 PMCID: PMC11035479 DOI: 10.1007/s00431-024-05483-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/09/2024] [Accepted: 02/12/2024] [Indexed: 03/02/2024]
Abstract
PURPOSE Gastric residual measurement is routinely performed in premature infants prior to feeding despite a lack of evidence of benefit. We aimed to evaluate if the exclusion of routine gastric residual measurement and evaluation has an impact on the time taken to achieve full enteral feeding in preterm neonates. METHODS International multi-centre randomised controlled trial. Clinically stable, appropriate for gestational age infants between 26+0 and 30+6 weeks of gestation and less than 1.5 kg birth weight were eligible. Infants were randomised to the intervention arm (no monitoring of gastric aspirates) or control arm (routine care). Primary outcome was the achievement of enteral feeds of 100 ml/kg/day by day 5 of life. RESULTS Ninety-five infants were recruited with 88 included in an intention-to-treat analysis, 45 in the intervention arm and 43 in the control arm. There was no imbalance in baseline characteristics. Thirty-three (73.3%) infants in the intervention group and 32 infants (74.4%) in the control group reached full feeds by day 5 of life (p = 0.91) with no difference in median time to full feeds. There were no statistically significant differences in survival or the major morbidities of prematurity. CONCLUSION There was no difference in time to attainment of enteral feeds of 100 ml/kg/day in premature infants when gastric residuals were not monitored. In the absence of a clinical benefit to routine monitoring, it may be appropriate to discontinue this practice and only monitor residuals when clinical concern of feeding intolerance or gastrointestinal pathology arises in this group of patients. TRIAL REGISTRATION NCT03111329- https://clinicaltrials.gov/ . Registered 06/04/2017. WHAT IS KNOWN • Previous randomized trials have shown little benefit to the performance of routine assessment of gastric residuals in preterm infants. Despite this, they continue to be performed due to concerns from observational data regarding development of NEC. Meta-analysis to date has failed to answer the question regarding NEC. WHAT IS NEW • In very low birth weight infants who are fed using modern feeding practice of faster feed advancement, to minimize use of central access and parenteral nutrition, exclusion of routine checks of gastric residuals did not increase the proportion of infants reaching full enteral feeds by day 5. No harm was seen when residual checks were not performed. • In the absence of a clinical benefit to the routine performance of gastric residuals in very low birth weight infants, it may be appropriate to discontinue their use and instead check residuals when clinical concern of pathology arises.
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Affiliation(s)
- A Branagan
- The Coombe Women and Infants University Hospital, Dublin 8, Ireland.
| | - C Murphy
- The Coombe Women and Infants University Hospital, Dublin 8, Ireland
| | - A O'Sullivan
- The Coombe Women and Infants University Hospital, Dublin 8, Ireland
| | - I Bodnarova
- Institute for the Care of Mother and Child, Prague, Czech Republic
| | - S Feyereislova
- Institute for the Care of Mother and Child, Prague, Czech Republic
| | - I Berka
- Institute for the Care of Mother and Child, Prague, Czech Republic
- 3rd School of Medicine, Charles University, Prague, Czech Republic
| | - J Miletin
- The Coombe Women and Infants University Hospital, Dublin 8, Ireland
- Institute for the Care of Mother and Child, Prague, Czech Republic
- UCD School of Medicine, University College Dublin, Dublin, Ireland
- 2nd Faculty of Medicine, Motol University Hospital, Prague, Czech Republic
| | - Z Stranak
- Institute for the Care of Mother and Child, Prague, Czech Republic
- 3rd School of Medicine, Charles University, Prague, Czech Republic
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Smazal AL, Ilahi IM, Raucci J, Robinson DT. Administering Parenteral Nutrition in the Neonatal Intensive Care Unit: Logistics, Existing Challenges, and a Few Conundrums. Clin Perinatol 2023; 50:557-573. [PMID: 37536764 DOI: 10.1016/j.clp.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Use of parenteral nutrition (PN) in the neonatal intensive care unit (NICU) requires evaluating the need for central venous catheters, potential drug incompatibilities, unintentional exposures, and suboptimal energy and nutrient intake during the transition to full enteral nutrition. Risks of photooxidation reactions in PN components, refeeding syndrome, and excess early amino acid intake should prompt the reevaluation of routine practices. The goal of this paper is to review the practicalities, challenges, and conundrums of administering PN in the NICU.
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Affiliation(s)
- Anne L Smazal
- Department of Pediatrics, Northwestern University Feinberg School of Medicine; Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Imran M Ilahi
- Department of Pediatrics, Northwestern University Feinberg School of Medicine; Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Janice Raucci
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Daniel T Robinson
- Department of Pediatrics, Northwestern University Feinberg School of Medicine; Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
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Wang D, Zhang SF. [Value of the combined use of aminotransferase-to-platelet ratio index and total bile acid for predicting parenteral nutrition-associated cholestasis in preterm infants with gestational age <34 weeks]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2023; 25:639-644. [PMID: 37382135 DOI: 10.7499/j.issn.1008-8830.2211124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
OBJECTIVES To explore the value of the combined use of aspartate aminotransferase-to-platelet ratio index (APRI) and total bile acid (TBA) for predicting parenteral nutrition-associated cholestasis (PNAC) in preterm infants with gestational age <34 weeks. METHODS A retrospective analysis was performed on medical data of 270 preterm infants born at <34 weeks of gestation who received parenteral nutrition (PN) during hospitalization in the First Affiliated Hospital of Wannan Medical College from January 2019 to September 2022, including 128 infants with PNAC and 142 infants without PNAC. The medical data between the two groups were compared, and predictive factors for the development of PNAC were explored through multivariate logistic regression analysis. The receiver operating characteristic (ROC) curve was used to evaluate the value of APRI alone, TBA alone, and the combination of both for predicting PNAC. RESULTS TBA levels in the PNAC group after 1, 2, and 3 weeks of PN were higher than those in the non-PNAC group (P<0.05). APRI in the PNAC group after 2 and 3 weeks of PN was higher than that in the non-PNAC group (P<0.05). Multivariate logistic regression analysis showed that elevated APRI and TBA after 2 weeks of PN were predictive factors for PNAC in preterm infants (P<0.05). ROC curve analysis showed that the sensitivity, specificity, and area under the curve (AUC) for predicting PNAC by combining APRI and TBA after 2 weeks of PN were 0.703, 0.803, and 0.806, respectively. The AUC for predicting PNAC by combining APRI and TBA was higher than that of APRI or TBA alone (P<0.05). CONCLUSIONS After 2 weeks of PN, the value of combining APRI and TBA for predicting PNAC is high in preterm infants with gestational age <34 weeks.
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Affiliation(s)
- Dan Wang
- Department of Pediatrics, First Affiliated Hospital, Wannan Medical College, Wuhu, Anhui 241000, China
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Effects of Early versus Standard Central Line Removal on the Growth of Preterm Infants with Very Low Birth Weight: A Non-Inferiority, Randomized Clinical Trial. Nutrients 2022; 14:nu14224766. [PMID: 36432453 PMCID: PMC9692930 DOI: 10.3390/nu14224766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 11/16/2022] Open
Abstract
Very preterm infants are usually supported by parenteral nutrition delivered through central lines (CLs) while progressing with enteral intake, although the optimal time point for their removal is unclear. This study evaluated the impact of the CL discontinuation time on the short-term growth outcomes of preterm infants. A non-inferiority, parallel-group, randomized controlled trial was conducted in four neonatal intensive care units in Poland. Preterm infants with very low birth weight (VLBW) without congenital abnormalities were eligible. Patients were allocated to discontinue central access at an enteral feeding volume of 100 mL/kg/day (intervention group) or 140 mL/kg/day (control group). The study's primary outcome was weight at 36 weeks' postmenstrual age, with a non-inferiority margin of -210 g. Overall, 211 patients were allocated to the intervention or control groups between January 2019 and February 2021, of which 101 and 100 were eligible for intention-to-treat analysis, respectively. The mean weight was 2232 g and 2200 g at 36 weeks' postmenstrual age in the intervention and control groups, respectively. The mean between-group difference was 32 g (95% confidence interval, -68 to 132; p = 0.531), which did not cross the specified margin of non-inferiority. No intervention-related adverse events were observed. Early CL removal was non-inferior to the standard type for short-term growth outcomes in VLBW infants.
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Valentine GC, Perez KM, Wood TR, Mayock DE, Comstock BA, Puia-Dumitrescu M, Heagerty PJ, Juul SE. Postnatal maximal weight loss, fluid administration, and outcomes in extremely preterm newborns. J Perinatol 2022; 42:1008-1016. [PMID: 35338252 DOI: 10.1038/s41372-022-01369-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 01/31/2022] [Accepted: 03/10/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Evaluate maximal weight loss (MWL) and total fluid administration (TFA) association in first week after birth with outcomes among extremely preterm (EP) newborns. STUDY DESIGN We performed a retrospective analysis of the Preterm Erythropoietin Neuroprotection Trial evaluating first-week MWL, TFA, and association with in-hospital outcomes. RESULTS Among n = 883 included EP neonates, n = 842 survived ≥ 7 days and were included in outcome analyses. MWL between 5% to 15% was associated with decreased odds of necrotizing enterocolitis compared to MWL > 15% (OR 0.49, 95% CI 0.25-0.98). Average TFA > 150 mL/kg birthweight/day was associated with increased odds of necrotizing enterocolitis (OR 3.22, 95% CI 1.40-7.42) and patent ductus arteriosus requiring surgery (OR 2.14, 95% CI 1.10-4.15). CONCLUSION MWL between 5% to 15% is a potentially optimal window of MWL. Increasing average TFA in the first week is associated with adverse neonatal outcomes. Prospective studies evaluating MWL and TFA and relationship to outcomes in EP neonates are needed. CLINICAL TRIAL REGISTRATION This study is a secondary analysis of pre-existing data from the PENUT Trial Registration: NCT01378273, https://clinicaltrials.gov/ct2/show/NCT01378273 .
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Affiliation(s)
- Gregory C Valentine
- Division of Neonatology, University of Washington/Seattle Children's Hospital, Seattle, WA, USA. .,Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine at Baylor College of Medicine, Houston, TX, USA.
| | - Krystle M Perez
- Division of Neonatology, University of Washington/Seattle Children's Hospital, Seattle, WA, USA
| | - Thomas R Wood
- Division of Neonatology, University of Washington/Seattle Children's Hospital, Seattle, WA, USA
| | - Dennis E Mayock
- Division of Neonatology, University of Washington/Seattle Children's Hospital, Seattle, WA, USA
| | - Bryan A Comstock
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Mihai Puia-Dumitrescu
- Division of Neonatology, University of Washington/Seattle Children's Hospital, Seattle, WA, USA
| | | | - Sandra E Juul
- Division of Neonatology, University of Washington/Seattle Children's Hospital, Seattle, WA, USA.,Center on Human Development and Disability, University of Washington, Seattle, WA, USA
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Abstract
Prematurity and other complications at birth are nutritional emergencies. Parenteral nutrition is a bridge to enteral nutrition for a few days or months, and sometimes the sole source of nutrition for life. Parenteral nutrition regimens are constructed to provide adequate and balanced energy, macronutrients, and micronutrients to support growth and prevent deficiencies. Neonatal parenteral nutrition regimens are complicated by periodic shortages of essential products, compatibility challenges, and contaminants. Newborns benefit from serial growth assessments, monitoring of biochemical status, nutrition-focused physical examinations, and management by a multidisciplinary team to ensure adequacy of parenteral nutrition and promote best outcomes.
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Affiliation(s)
- Sharon Groh-Wargo
- Nutrition and Pediatrics, Case Western Reserve University at MetroHealth Medical Center, 2500 MetroHealth Drive, C.G72, Cleveland, OH 44109-1998, USA
| | - Stephanie Merlino Barr
- Neonatal Dietitian, Department of Pediatrics, MetroHealth Medical Center, 2500 MetroHealth Drive, C.G72, Cleveland, OH 44109-1998, USA.
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Wang N, Zhang J, Yu Z, Tang B, Zhang L, Yin Y, Wang Z, Li S, Jiang S, Hou W, Gao Y, Wang H, Chen X, Deng X, Lu Y, Zhu L, Bo L, Han S. Evaluation of nutrition status of very preterm infants in neonatal intensive care units using different growth indicators. Nutr Clin Pract 2021; 36:1312-1319. [PMID: 34339517 DOI: 10.1002/ncp.10741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 06/06/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Nutrition status of very preterm infants in the neonatal intensive care unit (NICU) is strongly associated with postnatal growth. This study aimed to develop indicators of nutrition status using growth data of very preterm infants during hospitalization. METHODS The data of 596 newborns from eight NICUs were retrospectively analyzed. Inclusion criteria were birth at <32 weeks' gestation, NICU admission ≤24 h after delivery, and length of hospital stay ≥28 days. Three indicators were evaluated: (indicator I) prevalence of extrauterine growth restriction (EUGR); (indicator II) z-score for change in weight from birth to discharge, adjusted for birth weight z-score and gestational age; and (indicator III) change in weight z-score from birth to discharge, adjusted for birth weight z-score, gestational age, and time to regain birth weight. Using data from NICU 1 as the reference for the latter two indicators, we established linear regression models of the adjusted change in weight z-score from birth to discharge. The difference between the observed value and the baseline value (calculated by the two models) served as the nutrition indices. RESULTS The prevalence of EUGR differed significantly between the eight NICUs (P = .009). Statistically significant differences were found between the mean indices calculated by the other two models (all P < .05). CONCLUSIONS Indicator III, change in weight z-score from birth to discharge (adjusted for birth weight z-score, gestational age, and time to regain birth weight), appears to be the most accurate for evaluating the quality of nutrition in the NICU.
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Affiliation(s)
- Na Wang
- The Affiliated Suqian First People's Hospital of Nanjing Medical University, Suqian, Jiangsu, China
| | - Jia Zhang
- The Affiliated Suqian First People's Hospital of Nanjing Medical University, Suqian, Jiangsu, China
| | - Zhangbin Yu
- Nanjing Maternity and Child Health Care Hospital, Women's Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Bin Tang
- The Affiliated Suqian First People's Hospital of Nanjing Medical University, Suqian, Jiangsu, China
| | - Lin Zhang
- Changzhou Maternity and Child Health Care Hospital, Changzhou, Jiangsu, China
| | - Yujie Yin
- Jiangsu Province Hospital, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zengqin Wang
- Xuzhou Maternity and Child Health Care Hospital, Xuzhou, Jiangsu, China
| | - Shuangshuang Li
- Nantong Maternity and Child Health Care Hospital, Nantong, Jiangsu, China
| | - Shanyu Jiang
- Wuxi Maternity and Child Health Care Hospital, Wuxi, Jiangsu, China
| | - Weiwei Hou
- Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
| | - Yan Gao
- Lianyungang Maternity and Child Health Care Hospital, Lianyungang, Jiangsu, China
| | - Huaiyan Wang
- Changzhou Maternity and Child Health Care Hospital, Changzhou, Jiangsu, China
| | - Xiaoqing Chen
- Jiangsu Province Hospital, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xiaoyi Deng
- Xuzhou Maternity and Child Health Care Hospital, Xuzhou, Jiangsu, China
| | - Yi Lu
- Nantong Maternity and Child Health Care Hospital, Nantong, Jiangsu, China
| | - Lingling Zhu
- Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
| | - Lin Bo
- Lianyungang Maternity and Child Health Care Hospital, Lianyungang, Jiangsu, China
| | - Shuping Han
- Nanjing Maternity and Child Health Care Hospital, Women's Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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Branagan A, Perrem L, Semberova J, O’Sullivan A, Miletin J, Doolan A. Central catheter removal timing and growth patterns in preterm infants. Eur J Clin Nutr 2020; 74:1661-1667. [DOI: 10.1038/s41430-020-0645-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/15/2020] [Accepted: 04/22/2020] [Indexed: 11/09/2022]
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Very low birth weight infants receive full enteral nutrition within 2 postnatal weeks. J Perinatol 2020; 40:1849-1856. [PMID: 32994536 PMCID: PMC7522453 DOI: 10.1038/s41372-020-00819-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 07/30/2020] [Accepted: 09/10/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Identify whether an enteral nutrition goal of reaching full feeds by 7 postnatal days for infants 1-1.5 kg and by 14 postnatal days for infants <1 kg was feasible and its associated outcomes. STUDY DESIGN Very low birth weight infant cohort admitted in the first postnatal day and categorized as either Epoch 1 or Epoch 2, 12 months before and after implementation of a revised feeding protocol were compared. RESULT In Epoch 2, 83% infants born 1-1.5 kg and 77% infants born <1 kg reached full feeds by 7 and 14 days compared to 26% and 25%, respectively in Epoch 1 (p < 0.0001). Central line and parental nutrition days were significantly lower in Epoch 2 compared to Epoch 1 with sustained and potentially improved infant growth. CONCLUSION An evidence-based advancement feeding protocol was associated with achieving full feeds within the first 2 postnatal weeks for very low birth weight infants.
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