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Feed Tolerance PDF
Feed Tolerance PDF
Original Research
ABSTRACT
Background: Preterm neonates often have feed intolerance that needs to be differentiated from necrotizing enteroco-
litis. Gastric residual volumes (GRV) are used to assess feed tolerance but with little scientific basis.
Purpose: To compare prefeed aspiration for GRV and prefeed measurement of abdominal girth (AG) in the time taken to
reach full feeds in preterm infants.
Methods: This was a randomized controlled trial. Infants with a gestational age of 27 to 37 weeks and birth weight of
750 to 2000 g, who required gavage feeds for at least 48 hours, were included. Infants were randomized into 2 groups:
infants in the AG group had only prefeed AG measured. Those in the GRV group had prefeed gastric aspiration obtained
for the assessment of GRV. The primary outcome was time to reach full enteral feeds at 150 mL/kg/d, tolerated for at
least 24 hours. Secondary outcomes were duration of hospital stay, need for parenteral nutrition, episodes of feed intol-
erance, number of feeds withheld, and sepsis.
Results: Infants in the AG group reached full feeds earlier than infants in the GRV group (6 vs 9.5 days; P = .04). No
significant differences were found between the 2 groups with regard to secondary outcomes.
Implications for Practice: Our research suggests that measurement of AG without assessment of GRV enables preterm
neonates to reach full feeds faster than checking for GRV.
Implications for Research: Abdominal girth measurement as a marker for feed tolerance needs to be studied in infants
less than 750 g and less than 26 weeks of gestation.
Key Words: abdominal girth measurement, feed tolerance, gastric aspiration, NEC, preterm
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E14 Thomas et al
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Copyright © 2018 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
Gastric Residual Volumes Versus Abdominal Girth for Feed Tolerance in Preterm Neonates E15
or donor milk. The aspirated gastric contents are to cmm, abnormal absolute neutrophils count based on
be replaced if not altered. Control group aspirates Manroe or Mouzinho’s charts, thrombocytopenia,
were replaced per this protocol. or blood culture positive), and NEC stage 2 on mod-
The intervention was checking of AG at baseline, ified Bells classification.
that is, before feeds were initiated and at 2 hourly Data regarding feeds of the infant and demo-
intervals, before the next feed. In infants random- graphic details were recorded from the medical
ized to the AG group, aspiration of the feeding tube record. Demographic details included birth weight,
was not an aspect of the gastric assessment. Before weeks of gestation, gender, small for gestational age
commencement of the study, all nurses completed (SGA), maternal hypertension, abnormal antenatal
training on the measurement of AG. Girth was uni- Doppler, antenatal magnesium sulfate and steroids,
formly measured at the umbilicus using a flexible mode of delivery, need for resuscitation, need for
measuring tape touching skin but not compressing ventilation, hemodynamically significant ductus
tissue.23 Feeds were withheld if there were signs of FI arteriosus, placement of umbilical arterial catheter,
or if the girth increased by 2 cm or more.7 and time of starting feeds.
Sample size was calculated to be 24 in each group,
Current Unit Policy on Feeding During This assuming a difference in time to reach full feeds of 5
Study days, with a power of 80% and a .05 level of signifi-
Feeding was initiated, advanced, stopped, and cance.25 Statistical analysis was completed using the
restarted as per unit protocol derived by consensus t test or Mann-Whitney U test for continuous data
from a previous study.24 Trophic feeds, that is, 10 to and the χ2 test or Fischer exact test for categorical
20 mL/kg/d at 2 hourly intervals of either colostrum data. Statistical analysis was completed using SPSS
(if available) or donor human milk feeds are initi- version 20.0.
ated in hemodynamically stable infants preferably
on day 1 of life. Milk feeds consist of mother’s own RESULTS
milk or donor milk. Feeds are advanced by 20 mL/
kg/d (in infants 750-1249 g and those with abnor- During the study period, there were 754 infants born
mal antenatal Dopplers) or by 35 mL/kg/d (in who were between 26 and 37 weeks of gestation and
infants 1250-1499 g hemodynamically stable with between 750 and 2000 g. A majority of these infants,
static or decreasing ventilatory requirements). however, were not likely to need tube feeds for more
Infants weighing greater than 1500 to 2000 g may than 48 hours. Fifty-two infants randomized to each
be started on full feeds if they do not have abnormal arm of the study. The trial flow is shown in Figure
Dopplers, respiratory distress, asphyxia, or hemo- 1.Table 1 shows the baseline characteristics includ-
dynamic instability. Feeds are withheld if there are ing birth weight, gestational age, and comorbid con-
signs of FI, hemodynamic instability, suspected ditions. None were significantly different between
NEC, or voluminous gastric residuals. Feeds are the 2 groups. The mean birth weight was 1300 g and
restarted when all the aforementioned signs have mean gestation was 30 to 31 weeks.
resolved. Parenteral nutrition is continued till 100 Outcomes are shown in Table 2. The primary out-
mL/kg/d of feeds is reached. Full feeds are defined come of the time to reach full feeds was significantly
as 150 mL/kg/d. Feed intolerance is defined as the lower in the infants who had only AG checked. These
presence of any one of the following 4 features— infants reached full feeds 3 days earlier. The second-
abdominal distension of 2 cm or greater from the ary outcome of duration of hospital stay was lower
previous measurement, or vomiting 2 or more epi- in the AG group, but this difference did not reach
sodes in the past 6 hours or blood-stained or bilious statistical significance. There were also fewer with-
aspirates, or more than 2 episodes of voluminous held feeds in the AG group, but this was not statisti-
gastric aspirates in a 6-hour period. Voluminous cally significant. In the GRV group, feeds were with-
gastric residuals are defined as more than 50% of held because of more than 50% aspirates of previous
previous feed volume if 6 mL per feed or more, or 2 feed volume, altered aspirates and bilious aspirates,
episodes of more than 50% in a 6-hour period, or a and twice due to emesis. In the AG group, feeds were
single residue of 100% if feed volume is less than 6 withheld because of emesis and one occasion when
mL per feed. AG increased by more than 2 cm. There was no mor-
The primary outcome of this investigation was tality in either group. One infant in the GRV group
the time to reach full feeds (150 mL/kg/d), tolerated developed NEC and required a colostomy.
for at least 24 hours. Secondary outcomes were
number of episodes of FI, number of feeds that were DISCUSSION
withheld, duration of hospital stay, duration of par-
enteral nutrition, incidence of late-onset sepsis (as This randomized controlled trial showed that mea-
defined by a C-reactive protein (CRP)>1 mg/dL, suring AG as a marker for FI, instead of (or without)
total leucocyte count <5000/cmm or >25,000/ assessing GRV enabled preterm infants to reach full
Copyright © 2018 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
E16 Thomas et al
FIGURE 1
feeds faster. The newborns ranged from 26 weeks to catheter—all cause hypoxia or ischemia of the gut.28
37 weeks of gestation. Infants less than 26 weeks are Magnesium sulfate administration to the mother
at a higher risk for FI and NEC but were excluded. causes poor gut motility, thereby increasing FI. Ante-
This was done to first establish efficacy of AG mea- natal glucocorticoids are protective against NEC.
surement in slightly more mature neonates before it Time of feed initiation is an important determinant
is applied to the most vulnerable of infants. Preterm of time to reach full feeds—infants who receive early
infants older than 26 weeks were eligible for the enteral nutrition reach full feeds faster.29 Each of
study, including the late preterm infants weighing these baseline characteristics is an independent risk
more than 1500 g. These late preterm infants were factor for FI and hence they were compared between
randomized if they were likely to require gavage the 2 groups. We found no significant differences in
feeds for more than the first 48 hours of life. Thus, these baseline characteristics between the groups.
those who participated were sick infants who had In the only other study we found, Kaur et al25 also
experienced asphyxia, hemodynamic compromise, compared GRV and AG. Their results were similar
or were SGA. While NEC is primarily considered a and the infants in the AG group reached full feeds
disease of prematurity—bigger infants who are SGA significantly earlier. Their population, however, dif-
and have polycythemia, asphyxia, early-onset sepsis, fered in that they included only VLBW infants, but
congenital heart disease, or hypotension may excluded SGA infants, and those with asphyxia and
develop NEC.26,27 abnormal Dopplers. The present study includes this
Several baseline characteristics were compared “high-risk” population for NEC (30% had abnor-
between the 2 groups. These included SGA, mater- mal Dopplers, 34% were SGA, and 46% required
nal pregnancy-induced hypertension, maternal mag- resuscitation) and even in this group of infants, we
nesium sulfate administration, abnormal fetal Dop- found that full feeds were reached earlier when only
plers, antenatal glucocorticoid administration, need AG was measured.
for resuscitation, ventilation, hemodynamically sig- The primary concern about FI is differentiating
nificant ductus arteriosus, presence of an umbilical the progression to NEC. Some authors have shown
arterial catheter, and the time at which feeds were a correlation between the volume of aspirates and
started. Small for gestational age, maternal preg- NEC. Cobb et al30 in their retrospective case control
nancy induced hypertension (PIH), abnormal fetal study with 51 VLBW infants found that GRV are
Dopplers, need for resuscitation, HSPDA, ventila- increased in infants who subsequently developed
tion, and presence of an umbilical arterial NEC. The infants in their study had increased GRV
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Copyright © 2018 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
Gastric Residual Volumes Versus Abdominal Girth for Feed Tolerance in Preterm Neonates E17
Copyright © 2018 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
E18 Thomas et al
feeds. They, however, recommend that AG not be gastric residual volumes for the assessment of feed tol-
checked mainly due to a paucity of data.14 erance results in earlier full enteral feeds in preterm neo-
Among the secondary outcomes, the duration of nates. It may also decrease duration of hospital stay.
hospital stay was lower in the AG group. This differ-
ence was not statistically significant as the study was References
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