The effect of standardized feeding protocol on early outcome following gastroschisis repair: A systematic review and meta-analysis

Feeding practices for infants with gastroschisis: A survey of neonatal intensive care units in Canada

BackgroundFeeding practices for infants with gastroschisis are often based on institutional protocols, clinician judgement, and usual practice. The purpose of this study was to describe the range of feeding practices used in neonatal intensive care units across Canada.MethodsWe developed an 18-item survey with open-ended questions focused on feeding and nutrition among infants with gastroschisis. Clinicians from neonatal intensive care units that manage infants with gastroschisis were invited to participate. Interviews were completed via virtual meeting or email. Data were analyzed using descriptive statistics.ResultsSemi-structured interviews were conducted with 14 of 17 centers (82% response rate). Participants included neonatologists (12/14 centers) and dieticians (10/14 centers). Pediatric surgeons from 3/14 centers participated at the request of neonatologists. None of the centers reported using a gastroschisis feeding protocol routinely, although two centers noted occasional use of a protocol from another hospital, and another indicated that a gastroschisis feeding protocol is in development. All centers reported that patients with gastroschisis qualify for donor human milk if maternal breast milk is unavailable. Routine use of sham feeding, contrast studies, rectal irrigations, or motility agents was not reported. There was variation between centers regarding feeding advancement, type of formula used if breast milk is unavailable, use of probiotics, and strategies to introduce breastfeeding.ConclusionThere is variation in some but not all aspects of enteral feeding among infants with gastroschisis at neonatal intensive care units in Canada. The development of institutional feeding protocols and clinical practice guidelines may help standardize practice.

Breast Milk Feeding for Infants Who Required Major Surgery

OBJECTIVE

To identify barriers or facilitators that influenced mothers to provide mother's own milk (MOM) for 6 months to their infants who were hospitalized in the NICU after major surgery.

DESIGN

Descriptive qualitative.

SETTING

An 80-bed, Level 4 NICU of a regional pediatric hospital in the western United States.

PARTICIPANTS

Fourteen mothers who provided MOM for their infants who required surgery within 1 week of age.

METHODS

We conducted in-person interviews upon admission and discharge of the infant, phone interviews 1 and 2 weeks after discharge, and phone interviews monthly for 6 months or until discontinuance of the provision of MOM. We analyzed interviews using the Brooks thematic template analysis method.

RESULTS

Eleven infants received exclusive MOM at discharge, and nine infants remained on exclusive MOM at 6 months. We generated four principal themes from the participants' comments: Value of Breast Milk, Challenges of Providing MOM, Emotional Fluctuation, and Coping With Reality of Circumstances.

CONCLUSION

Internalizing the value of MOM, family support, and coping with barriers were key factors that influenced participants to provide MOM for at least 4 months. Findings of this study suggest that prenatal education with anticipatory guidance and lactation support in the NICU can help mothers achieve the goal of extended provision of MOM to infants with serious conditions that require surgery. Education and support may be especially helpful for young, first-time mothers.

Nutritional Considerations in Neonates Requiring Gastrointestinal Surgery

Neonates who require gastrointestinal surgery are a complex group of patients that require special consideration with regard to nutritional supplementation and growth. During the acute postoperative phase, a major stress response causes catabolism with degradation of the body's nutrient stores leading to poor growth. Following surgery, parenteral nutrition is often required to support the surgical neonate; although, enteral nutrition, if feasible, is critical because it helps improve intestinal adaptation. However, the best type, mode, and duration of feeding is not established in the current literature. It is important to factor in the individual patient anatomy and site of intestinal resection when considering intestinal absorptive ability because these patients are at high risk for nutrient malabsorption, with the risk persisting even when enteral autonomy is achieved. The neonate undergoing gastrointestinal surgery requires close growth and nutritional monitoring both during the neonatal period but also into later life because risks of abnormalities persist. In this review, we summarize the impact of gastrointestinal surgery and postoperative intestinal changes on infant growth and nutrition.

Association between early enteral nutrition and length of stay in neonates with congenital bowel obstruction: A retrospective cohort study

BACKGROUND

The optimal feeding strategy for postoperative neonatal patients with congenital bowel obstruction is widely debated. This study aims to evaluate perioperative characteristics and postoperative nutrition practices for patients with congenital bowel obstruction. We hypothesized that earlier introduction of enteral nutrition (EN) is associated with shorter hospital stays and increased weight gain velocities.

METHODS

We performed a retrospective cohort study on neonatal patients (<30 days old) admitted to a pediatric referral hospital who underwent an operation for bowel obstruction between 2010 and 2020. Demographic information, clinical characteristics, and feeding characteristics were collected. Associations between early EN (EEN), defined as commencement of enteral feeding within 5 days of surgery, and perioperative characteristics were analyzed with SAS 9.4.

RESULTS

Of the 97 neonates with congenital bowel obstruction, 36 patients received EEN. Sex, gestational age, and ethnicity were similar between groups. Patients receiving EEN were more likely to have a diagnosis of malrotation, anorectal malformation, or annular pancreas (P = 0.04). Patients receiving EEN weaned from parenteral nutrition earlier (9 vs 17 days, P = 0.005). Receiving EEN was associated with shorter median hospital stay (16 vs 29 days, P < 0.0001). Weight gain velocities at the 2-month follow-up were greater for patients receiving EEN (8.02 vs 7.00 g/kg/day, P = 0.04) with the difference dissipating at 6 months.

CONCLUSION

EEN was more likely provided in patients with certain operative diagnoses and was associated with improved outcomes. Creating and implementing an EEN protocol in congenitally obstructed neonates may lead to shorter hospital stays and improved outcomes.

Inter-center variations in inpatient outcomes for infants with gastroschisis from the Children's Hospitals Neonatal Consortium

OBJECTIVE

To estimate inter-center variation (ICV) in hospital length of stay (LOS) and oral feeding at discharge among infants with gastroschisis.

STUDY DESIGN

The Children's Hospitals Neonatal Consortium's (CHNC) database was used to identify hospitalized survivors with gastroschisis. Two outcomes were evaluated: LOS and discharge without tube feedings. Hospital outcomes were evaluated in unadjusted and adjusted analyses. Generalized linear models with log link for gamma distribution were used to model LOS and logistic regression for discharge without tube feeds.

RESULTS

For 3987 surviving infants with gastroschisis, LOS and discharge within 70 days with exclusively oral feeding both exhibited significant ICV. Differences persisted in multivariable analyses. Risk-adjusted LOS (68% difference) and oral feeding at discharge (6.4-fold difference) varied significantly between centers.

CONCLUSION

Hospital of care was independently associated with LOS and exclusive oral feeding at discharge rates for infants with gastroschisis. Management differences, potentially influenced by parental preferences, contributed to variation.

Association between consensus-based nutrition pathway and growth faltering in infants with gastroschisis: A retrospective cohort study

BACKGROUND

The University of California Fetal Consortium published that 55% of infants with gastroschisis develop growth faltering by hospital discharge. To address this problem, we developed a nutrition pathway emphasizing (1) early provision of parenteral macronutrients, (2) use of human milk, and (3) growth faltering treatment. This study's goals were to assess adherence to and efficacy of this pathway in infants with gastroschisis across six California hospitals.

METHODS

In 2015, the consortium standardized the care for infants with gastroschisis. To decrease growth faltering rates, between 2019 and 2020, nutrition guidelines were proposed, discussed, revised, and initiated. This study's primary outcome was weight or linear growth faltering (z score decline ≥0.8 in weight or length) at hospital discharge. Adherence measures were assessed.

RESULTS

One hundred twenty-six infants with gastroschisis were born prepathway; 52 were born postpathway. Median gestational age was similar between cohorts. Adherence to components of the pathway ranged from 58% to 95%. The proportion of infants with weight or linear growth faltering at discharge was lower after pathway initiation (59.4% vs 36.2%, P = 0.0068). Adjusting for gestational age and fetal growth restriction, the pathway was associated with decreased weight or linear growth faltering (odds ratio [OR] 0.35 [0.16-0.75], P = 0.0060) and decreased linear growth faltering (OR 0.24 [0.096-0.56], P = 0.0062) at discharge. Hypertriglyceridemia, cholestasis, and days to full feeds were similar to published cohorts.

CONCLUSION

Fewer infants with gastroschisis experienced weight or length growth faltering at hospital discharge following the implementation of a multicenter nutrition pathway.

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.

Role of practice standardization in outcome optimization for CDH

Standardization of care seeks to improve patient outcomes and healthcare delivery by reducing unwanted variations in care as well as promoting the efficient and effective use of healthcare resources. There are many types of standardization, with clinical practice guidelines (CPGs), based on a stringent assessment of evidence and expert consensus, being the hallmark of high-quality care. This article outlines the history of CPGs, their benefits and shortcomings, with a specific focus on standardization efforts as it relates to congenital diaphragmatic hernia management.

European reference network for rare inherited congenital anomalies (ERNICA) evidence based guideline on the management of gastroschisis

BACKGROUND

The European Reference Network for rare Inherited Congenital Anomalies, ERNICA, guidelines for gastroschisis cover perinatal period to help teams to improve care.

METHOD

A systematic literature search including 136 publications was conducted. Research findings were assessed following the GRADE methodology. The evidence to decision framework was used to determine the strength and direction of recommendations.

RESULTS

The mode or timing of delivery do not impact neonatal mortality, risk of NEC or time on parenteral nutrition (PN). Intra or extra abdominal bowel dilatation predict complex gastroschisis and longer length of hospital stay but not increased perinatal mortality. Outcomes after Bianchi procedure and primary fascia closure under anesthesia are similar. Sutureless closure decreases the rate of surgical site infections and duration of ventilation compared to surgical closure. Silo-staged closure with or without intubation results in similar outcomes. Outcomes of complex gastroschisis (CG) undergoing early or delayed surgical repair are similar. Early enteral feeds starting within 14 days is associated with lower risk of surgical site infection.

RECOMMENDATIONS

The panel suggests vaginal birth between 37 and 39 w in cases of uncomplicated gastroschisis. Bianchi's approach is an option in simple gastroschisis. Sutureless closure is suggested when general anesthesia can be avoided, sutured closure. If anesthesia is required. Silo treatment without ventilation and general anesthesia can be considered. In CG with atresia primary intestinal repair can be attempted if the condition of patient and intestine allows. Enteral feeds for simple gastroschisis should start within 14 days.

Standardizing vitamin D supplementation to minimize deficiency in children with intestinal failure

BACKGROUND

Vitamin D deficiency is present in 40%-70% of children with intestinal failure (IF), yet there are no published guidelines for repleting and maintaining vitamin D levels in this population. The purpose of this study is to evaluate the efficacy of a standardized vitamin D algorithm in reducing the incidence of deficiency.

METHODS

A retrospective chart review was performed in children with IF who had at least one serum vitamin D (25-hydroxyvitamin D3 ) measurement. Vitamin D levels were compared prealgorithm (2014-2016) and during active-algorithm use (2018-2020). Vitamin D levels were classified as severe deficiency (<12.5 nmol per L), mild deficiency (12.5-39 nmol/L), insufficiency (40-74 nmol/L), optimal (75-224 nmol/L), or toxicity (>225 nmol/L). Descriptive and comparative statistics were calculated using a linear mixed-effects model, with P < 0.05 considered significant.

RESULTS

Twenty-eight children with IF were enrolled, which included 157 vitamin D measurements (58 in the prealgorithm group and 98 in the active-algorithm group). Algorithm compliance was 4% in the prealgorithm group and 61% in the active-algorithm group. Active-algorithm patients had improved vitamin D levels in all categories compared with those of prealgorithm patients (mild deficiency: 8% vs 9%; insufficiency: 41% vs 72%; optimal: 50% vs 19%). Algorithm use was found to have a statistically significant effect on serum vitamin D levels (β = 21.58; 95% confidence interval, 14.11-29.05; P < 0.005).

CONCLUSIONS

Children with IF are at high risk for vitamin D deficiency. Use of a standardized vitamin D supplementation algorithm was associated with increased serum vitamin D levels.

Utility of Hospital Failure to Rescue for Analyzing Variation in Pediatric Postoperative Mortality

OBJECTIVES

To evaluate the association between pediatric hospital performances in terms of failure to rescue (FTR), defined as postoperative mortality after a surgical complication, and mortality among patients without a surgical complication.

DESIGN

Retrospective cohort study.

SETTING

Forty-eight academic, pediatric hospitals; data obtained from Pediatric Health Information System database (Child Health Corporation of America, Shawnee Mission, KS) (2012-2020).

PATIENTS

Children who underwent at least one of 57 high-risk operations associated with significant postoperative mortality.

EXPOSURES

Hospitals were stratified into quintiles of reliability adjusted FTR (lower than average FTR in quintile 1 [Q1], higher than average FTR in quintile 5 [Q5]). Multivariable hierarchical regression was used to evaluate the association between hospital FTR performance and mortality among patients who did not have a surgical complication.

MEASUREMENTS AND MAIN RESULTS

Among 203,242 children treated across 48 academic hospitals, the complication and overall postoperative mortality rates were 8.8% and 2.3%, respectively. Among patients who had a complication, the FTR rate was 8.8%. Among patients who did not have a complication, the mortality rate was 1.7%. There was a 6.5-fold increase in reliability adjusted FTR between the lowest and highest performing hospitals (lowest FTR hospital-2.7%; 95% CI [1.6-3.9]; highest FTR hospital-17.8% [16.8-18.8]). Complex chronic conditions were highly prevalent across hospitals (Q1, 72.7%; Q2, 73.8%; Q3, 72.2%; Q4, 74.0%; Q5, 74.8%; trend test p < 0.01). Relative to Q1 hospitals, the odds of mortality in the absence of a postoperative complication significantly increased by 33% at Q5 hospitals (odds ratio 1.33; 95% CI [1.07-1.66]). This association was consistent when limited to patients with a complex chronic condition and neonates.

CONCLUSION

FTR may be a useful and valid surgical quality measure for pediatric surgery, even when considering patients without a postoperative complication. These findings suggest practices and processes for preventing FTR at high performing pediatric hospitals might help mitigate the risk of postoperative mortality even in the absence of a postoperative complication.

Hospital Variation in Mortality and Failure to Rescue after Surgery for High-Risk Neonatal Diagnoses

INTRODUCTION

A large proportion of postoperative mortality after pediatric surgery occurs among neonates with specific high-risk diagnoses. The extent to which there is hospital-level mortality variation among patients with these diagnoses and whether this variation is associated with differences in failure to rescue (FTR) is unclear.

METHODS

The Pediatric Health Information System® database (2012-2020) was used to identify patients who underwent surgery for eight high-risk neonatal diagnoses: gastroschisis; volvulus; necrotizing enterocolitis; intestinal atresia; meconium peritonitis; tracheoesophageal fistula; congenital diaphragmatic hernia; and perinatal intestinal perforation. Hospitals were stratified into tertiles of reliability-adjusted inpatient mortality rates (lower than average mortality - tertile 1 [T1]; higher than average mortality - tertile 3 [T3]). Multivariable hierarchical regression was used to evaluate the association between hospital-level, reliability-adjusted mortality and FTR.

RESULTS

Overall, 20,838 infants were identified across 48 academic, pediatric hospitals. Adjusted hospital mortality rates ranged from 4.0% (95% CI, 0.0-8.2) to 16.3% (12.2-20.4). Median case volume (range, 80-1,238) and number of NICU beds (range, 24-126) were not significantly different across hospital tertiles. Compared to the hospitals with the lowest postoperative mortality (T1), the odds of FTR were significantly higher in hospitals with the highest (T3) postoperative mortality (odds ratio 1.97 [1.50-2.59]).

CONCLUSIONS

Significant variation in neonatal hospital mortality for high-risk diagnoses does not appear to be explained by hospital structural characteristics. Rather, difference in FTR suggests quality improvement interventions targeting early recognition and management of postoperative complications could improve surgical quality and safety for high-risk neonatal care.

Does time to theater matter in simple gastroschisis?

Objective

A recent publication has suggested that expedited time to theater in gastroschisis results in higher rates of primary closure and decreases the length of stay (LOS). This study primarily aims to assess the impact of time to first management of neonates with gastroschisis on the LOS.

Methods

Neonates admitted between August 2013 and August 2020 with gastroschisis were included. Data were collected retrospectively, and neonates with complex gastroschisis were excluded. Variables including gestation, birth weight, time of first management, primary/delayed closure and use of patch were evaluated as possible confounding variables. The outcome measures were time to full feeds, time on parenteral nutrition (PN) and LOS. Univariate and multivariate linear regression analyses were performed. P<0.05 was regarded as significant.

Results

Eighty-six neonates were identified, and 16 were then excluded (eight patients with complex gastroschisis, eight patients with time to first management not documented). The median LOS for those who underwent primary closure was 21 days (interquartile range (IQR) =16-29) and for those who underwent silo placement and delayed closure was 59 days (IQR=44-130). The mean time to first management was 473 min (standard deviation (SD) =146 min), with only 20% of these infants being operated on at less than 6 hours of age. Univariate and multivariate analyses demonstrated no relationship between time to first management and LOS (r2=0.00, p=0.82) but did demonstrate a consistent positive association between time to first feed and LOS and delayed closure, resulting in a longer time to full feeds and a longer time on PN.

Conclusions

The time to first management was not associated with a change in LOS in these data. Further prospective evaluation of the impact of reducing the time to first feed on the LOS is recommended.

Level of evidence

IV.

Gastroschisis for the Gastroenterologist: Updates on Epidemiology, Management, and Outcomes

Gastroschisis is a common congenital abdominal wall defect, likely influenced by environmental factors in utero, with increasing prevalence in the United States. Early detection of gastroschisis in utero has become the standard with improved prenatal care and screening. There are multiple surgical management techniques, though sutureless closure is being used more frequently. Postoperative feeding difficulty is common and requires vigilance for complications, such as necrotizing enterocolitis. Infants with simple gastroschisis are expected to have eventual catch-up growth and normal development, while those with complex gastroschisis have higher morbidity and mortality. Management requires collaboration amongst several perinatal disciplines, including obstetrics, maternal fetal medicine, neonatology, pediatric surgery, and pediatric gastroenterology for optimal care and long-term outcomes.

Nutrition considerations in pediatric surgical patients

Children who require surgical interventions are subject to physiologic stress, necessitating a period of healing when nutrition needs may temporarily change. Providing appropriate nutrition to children before and after surgery is an important part of minimizing surgical morbidity. There is a clear link between poor nutrition and surgical outcomes, therefore providing good reason for ensuring an appropriate nutrition plan is in place for children requiring surgery. This review will address recent research investigating nutrition considerations for pediatric surgical patients with a focus on practical tools to guide decision making in the preoperative, intraoperative, and postoperative periods.