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ADC-FNN Online First, published on December 31, 2014 as 10.1136/archdischild-2014-307067 Original article

A randomised trial of re-feeding gastric residuals in preterm infants Ariel A Salas,1 Alain Cuna,2 Ramachandra Bhat,3 Gerald McGwin Jr,4 Waldemar A Carlo,5 Namasivayam Ambalavanan5 1

Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania, USA 2 Department of Pediatrics, University of Missouri-Kansas City, Kansas City, Missouri, USA 3 Department of Pediatrics, University of Maryland, Baltimore, Maryland, USA 4 Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA 5 Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA Correspondence to Dr Namasivayam Ambalavanan, Department of Pediatrics, University of Alabama at Birmingham, Women and Infants Center, 1700 6th Ave South, Suite 9380, Birmingham, AL 35249, USA; nambalavanan@peds. uab.edu Received 27 June 2014 Revised 20 November 2014 Accepted 7 December 2014

ABSTRACT Objective To determine whether re-feeding of gastric residual volumes reduces the time needed to achieve full enteral feeding in preterm infants. Design Parallel-group randomised controlled trial with a 1:1 allocation ratio. Setting Regional referral neonatal intensive care unit. Patients 72 infants of gestational age 230/7 to 286/7 weeks receiving minimal enteral nutrition (24 h in nearly 75% of all extremely preterm infants.5 6 This is despite clinical evidence showing that early establishment of enteral nutrition is associated with reductions in severity of critical illness and long-lasting benefits on linear growth and neurodevelopmental outcomes.5–7

What is already known on this topic ▸ When clinicians choose to continue feeds after identification of gastric residuals in preterm infants, gastric residuals can be either re-fed or discarded to feed only fresh human milk/ formula. ▸ There is no evidence from clinical trials to support either approach.

What this study adds ▸ Re-feeding practices are likely safe in extremely preterm infants. ▸ The mean time to achieve full enteral feeds is not affected by re-feeding gastric residuals, except in formula-fed infants.

The magnitude and characteristics of gastric residual volumes combined with specific findings on the abdominal examination are usually considered by clinicians in decisions to continue with the scheduled enteral feeding plan.1 8 Enteral feeding can be continued by either re-feeding gastric residual volumes or by discarding gastric residual volumes and feeding only fresh human milk or formula.9 Because gastric acid facilitates protein digestion10 11 and protects against entrance of bacteria into the gastrointestinal tract,12 re-feeding gastric residual volumes may potentially facilitate normal continuation of digestion without increasing the risk of infection and may reduce the risk of further feeding intolerance, and thus expedite feeding advancement. Conversely, because prolonged periods of gastric alkalinity occur in preterm infants during the first days after birth,10 a limited gastric acid production may cause bacterial overgrowth in the gastric content of preterm infants,11 12 and re-feeding gastric residual volumes may possibly increase the risk of NEC and other infections. In view of a lack of evidence from clinical trials to support either approach,6 13 we conducted this randomised trial to determine whether re-feeding of gastric residual volumes would reduce the time needed to achieve full enteral feeding in preterm infants and to determine whether the rate of spontaneous intestinal perforation (SIP), NEC and/or death would differ between intervention groups.

Salas AA, et al. Arch Dis Child Fetal Neonatal Ed 2014;0:F1–F5. doi:10.1136/archdischild-2014-307067

F1

Copyright Article author (or their employer) 2014. Produced by BMJ Publishing Group Ltd (& RCPCH) under licence.

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Original article METHODS Trial design and participants This study was a parallel-group randomised controlled trial with a 1:1 allocation ratio conducted at the neonatal intensive care units of the University of Alabama at Birmingham Hospital and the Children’s of Alabama Hospital (Clinicaltrials.gov: NCT01420263). Infants with gestational age between 230/7 and 286/7 weeks receiving minimal enteral nutrition (defined as enteral feeding volume of 2 mL), gastric residual volumes were either re-fed (Re-feeding group) or discarded followed by feeding of fresh human milk or formula (Fresh-feeding group) if the clinician’s decision was to continue enteral feeding. Because slightly greenish or dark yellow gastric residual volumes are common in preterm infants,1 14 only gastric residual volumes containing blood on visual inspection by bedside nurses were not re-fed. Additional testing to confirm the presence of blood in gastric residual volumes was not required. Small gastric residual volumes (12 h) Number of cases (%) 10/29 (34) 13/30 (43) 95% confidence limits 16–53 24–62 Length of hospital stay, days Mean±SD 91.6±43.1 93.5±48.4 95% confidence limits 75.2–108.0 75–111.6 Min–max 32–261 34–261

p Value

0.11

0.70

0.83

0.49

0.87

DISCUSSION The results of this trial show that re-feeding gastric residual volumes does not reduce the time needed to achieve full enteral feeding in extremely preterm infants. The composite outcome of SIP, surgical NEC or death during hospitalisation did not differ between the groups. In a prespecified subgroup analysis, infants receiving formula randomised to fresh-feeding had a significant delay in time to full enteral feeding. To our knowledge, this is the first randomised controlled trial comparing the freshfeeding and re-feeding approaches for management of gastric residual volumes in preterm infants. Previous studies have reported that human milk reduces the time to full enteral feeding,15 reduces the risk of feeding intolerance16 17 and reduces the incidence of NEC17 in preterm infants. In this trial, no difference in time to full enteral feeding between formula-fed infants and human milk-fed infants was found. The delay in time to achieve full enteral feeding observed in formula-fed infants randomised to fresh-feeding suggests that digestion of high-protein preterm formula might be affected by characteristics of the gastric content. The optimal gastric pH for enhanced pepsin activity and protein hydrolysis is pH

A randomised trial of re-feeding gastric residuals in preterm infants.

To determine whether re-feeding of gastric residual volumes reduces the time needed to achieve full enteral feeding in preterm infants...
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