Partial Enteral Discharge Programs for High-risk Infants

Home nasogastric tube program for NICU infants: a seven year retrospective outcome analysis

Objectives

The goal of this study was to assess the safety and effectiveness of a Home Nasogastric Program for infants admitted to a Neonatal Intensive Care Unit (NICU).

Study design

We performed a retrospective chart review of infants discharged from a Level III NICU to a Home Nasogastric (HNG) follow-up clinic from December 2014-February 2022. Data was recorded for two years post discharge from the NICU.

Results

83 infants were included in this study. There were no emergency department visits related to feeding tube dysfunction or nasogastric (NG) tube equipment malfunctions. The number of days the NG tube was used median (IQR): 3 (2-10). Seventy-seven (93%) infants had no documented feeding problems at the end of the follow-up period. We estimate 556 hospitalization days avoided resulting in cost savings.

Conclusion

The Home NG program was safe and effective. This program decreased length of NICU stay and health care associated costs.

Comparison of Infants Discharged from Birth Hospitalization with Gastrostomy versus Nasogastric Feeding Tube

Many infants, particularly those born premature or with medical complexity, require supplemental enteral nutrition upon discharge from birth hospitalization. Recent literature supports the safety of discharging infants with nasogastric tube (NG) feeding. However, further evidence is needed to characterize populations suited for home NG feeding compared to gastrostomy tube (GT) placement. This study aimed to describe demographic and clinical differences between infants discharged from birth hospitalization with NG versus GT feeding.This retrospective cohort study included infants discharged from birth hospitalization with NG or GT feeding between April 2014 and December 2022 at a single quaternary care hospital with a neonatal intensive care unit (NICU). Routinely collected health data were used to investigate associations between patient characteristics and discharge feeding modality, as well as assess feeding outcomes 12 months after discharge.Of 346 infants, 72 (20.8%) were discharged with NG and 274 (79.2%) with GT. Infants with GT were more often discharged from the NICU (71.2 vs. 26.4%) with lower birth weights (median 2.40 vs. 2.92 kg) and longer hospitalizations (median 84 vs. 51.5 days). Twelve months after discharge, 77.4% of NG infants achieved full oral feeding compared to 16.6% of GT infants with earlier tube discontinuation in NG infants (19 vs. 236 days).Home NG feeding is a viable, less invasive alternative to GT for selected infants, particularly those with less medical complexity. Prospective studies are needed to further delineate optimal discharge feeding modalities for various infant subpopulations. · Infants discharged with gastrostomies had lower birth weights.. · More NG tube infants achieved oral feeding than gastrostomy infants.. · NG tubes were removed much sooner than GT.. · Home NG feeding is an alternative to gastrostomy for less medically complex infants..

Managing Home Oxygen and Nasogastric Feeds Post-NICU Discharge: PCP Practices and Perspectives

OBJECTIVE

 NICU graduates are frequently technology dependent including home oxygen, pulse oximetry, and/or nasogastric (NG) feedings. Primary care provider (PCP) perceptions, practices, and barriers to managing these infants are not well described, especially at altitude. We sought to 1) describe PCP comfort and 2) determine practices and barriers in managing this technology at higher altitudes.

STUDY DESIGN

 This cross-sectional survey assessed Colorado and Wyoming PCP perceptions and practices surrounding technology in NICU graduates. We explored bivariate analysis between clinic altitude, location, and provider's experience with comfort caring for infants discharged with technology using chi-squared or Fisher's exact tests. Significant relationships were modeled using logistic regression for odds ratios and 95% confidence intervals.

RESULTS

 Among 203 respondents, 82% were pediatricians, and 86% practiced in urban/suburban environments. Clinic altitude ranged 2,500-9,000 ft. PCPs endorsed comfort managing oxygen in term (92%) and moderately/late preterm infants (82%), versus 52% comfort in very/extremely preterm infants. 62% utilized an oxygen-weaning algorithm. Comfort managing oxygen was greater in suburban versus urban locations (odds ratio [OR] = 4.4, 95% confidence interval [CI]: 1.6-11.7) and providers practicing for >10 versus <5 years (OR = 3.5, 95% CI: 1.5, 8.4). 60% found pulse oximetry useful, though 70% perceived caregiver stress. 69% accepted infants on NG feeds, though 61% endorsed discomfort with management.

CONCLUSION

 PCPs are comfortable managing home oxygen in moderately preterm to term infants but find caring for most preterm infants challenging. Discomfort in managing NG feeds is prevalent. This highlights peridischarge barriers and improvement opportunities for high-risk, technology-dependent infants.

KEY POINTS

· PCPs are uncomfortable managing very/extremely preterm infants on home oxygen after NICU discharge.. · PCPs perceive frequent commercial pulse oximetry use in NICU graduates.. · Most PCPs are uncomfortable managing home NG feedings..

Method of home tube feeding and 2-3-year neurodevelopmental outcome

OBJECTIVE

To describe the Bayley Scales of Infant Development 3rd Edition (Bayley-III) of infants discharged home receiving tube feeds.

STUDY DESIGN

Retrospective review of infants discharged with nasogastric or gastrostomy tube feeds and completed a Bayley-III assessment at 2-3-years of age through a neonatal follow-up program. Results were reported using descriptive statistics.

RESULTS

Of infants discharged with nasogastric feeds, median Bayley-III scores were in the low-average to average range, and full oral feeds were achieved in 75%. Of infants discharged with gastrostomy tube feeds, median Bayley-III scores were in the extremely low range, and full oral feeds were achieved in 36%. Our data set did not demonstrate a distinct patient demographic that correlated to the type of feeding tube at discharge.

CONCLUSION

Neurodevelopmental outcome at 2-3 years does not appear to be negatively impacted by the decision to discharge an infant from the NICU with home NG feedings.

Feeding dysfunction in NICU patients with cramped synchronized movements

Patients admitted to the neonatal intensive care unit (NICU) have higher association for neurodevelopment deficits, specifically cerebral palsy (CP). We identified patients with risk for CP using abnormal Pretchl's General Movement Assessment (GMA) and sub-category of cramped synchronized movements (CSM) and reported their feeding outcomes at discharge. Over 75 % of these patients required either nasogastric (NGT) or gastrostomy tube (GT) at discharge. Of these, 57 % weaned off their NGT or GT at home and 43 % of patients still needed a GT one year after discharge. Of those that could not wean off their NGT or GT, these patients had longer hospital stay, took lower percentage by mouth, and an older post-menstrual age at discharge. We did not find a difference in NGT or GT use between patients with IVH, ELBW, nor between their birthweight or gestation age at birth. This study provides further clinical characteristics in NICU patients who have higher risk of CP, and supports the need for skilled feeding therapy and resources both during and after NICU admission.

Characteristics and Outcomes of Children Discharged With Nasoenteral Feeding Tubes

OBJECTIVES

To describe the characteristics and outcomes of children discharged from the hospital with new nasoenteral tube (NET) use after acute hospitalization.

METHODS

Retrospective cohort study using multistate Medicaid data of children <18 years old with a claim for tube feeding supplies within 30 days after discharge from a nonbirth hospitalization between 2016 and 2019. Children with a gastrostomy tube (GT) or requiring home NET use in the 90 days before admission were excluded. Outcomes included patient characteristics and associated diagnoses, 30-day emergency department (ED-only) return visits and readmissions, and subsequent GT placement.

RESULTS

We identified 1815 index hospitalizations; 77.8% were patients ≤5 years of age and 81.7% had a complex chronic condition. The most common primary diagnoses associated with index hospitalization were failure to thrive (11%), malnutrition (6.8%), and acute bronchiolitis (5.9%). Thirty-day revisits were common (49%), with 26.4% experiencing an ED-only return and 30.9% hospital readmission. Revisits with a primary diagnosis code for tube displacement/dysfunction (10.7%) or pneumonia/pneumonitis (0.3%) occurred less frequently. A minority (16.9%) of patients progressed to GT placement within 6 months, 22.3% by 1 year.

CONCLUSIONS

Children with a variety of acute and chronic conditions are discharged from the hospital with NET feeding. All-cause 30-day revisits are common, though revisits coded for specific tube-related complications occurred less frequently. A majority of patients do not progress to GT within a year. Home NET feeding may be useful for facilitating discharge among patients unable to meet their oral nutrition goals but should be weighed against the high revisit rate.

Failure to thrive, oral intake, and inpatient status prior to gastrostomy tube placement in the first year of life is associated with persistent use 1-year later

BACKGROUND

Gastrostomy tube (GT) placement is a common procedure in infants (≤1-year-old). There is variation in patient selection and a paucity of studies examining which patients require long term enteral access. The objective of this study was to assess demographic and clinical factors associated with persistent GT use (PGU) at 1-year after placement.

METHODS

We performed a single-institution retrospective review of patients ≤1-year-old who underwent GT placement from January 31, 2014, and January 31, 2020, using institutional NSQIP-P data supplemented with chart review. Multivariable logistic regression analysis was performed to identify factors associated with PGU. Clinical predictors were selected a priori, and a p-value less than 0.05 was used to detect a significant association.

RESULTS

140 patients were included, and 118 had a 1-year follow-up. At 1-year following GT placement, 38 patients had weaned from their GT (32.2%). Failure to thrive (FTT), and inpatient admission prior to surgery are associated with increased odds of PGU at 1-year after surgery, OR: 5.19 and 6.02, respectively. There is an inverse association between the percentage of feeds taken by mouth at the time of surgery and the odds of PGU at 1-year (OR: 0.03).

CONCLUSION

Patients who have FTT (documented prior to surgery) or an inpatient admission prior to GT had a higher odds of PGU at 1-year post-op. Additionally, the amount taken by mouth at the time of GT placement was inversely related to PGU. These factors are important in determining the need for a surgical gastrostomy tube.

LEVEL OF EVIDENCE

II.