Pediatrics and Neonatology (2015) 56, 136e137
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.pediatr-neonatol.com
LETTER TO THE EDITOR
Gastric Residuals, Feeding Intolerance, and Necrotizing Enterocolitis in Preterm Infants To the Editor, We read with interest the recent review article by Yue-Feng Li et al 1, describing the correlation between the gastric emptying, gastric residuals, and feeding intolerance in very low birth weight (VLBW) infants. They speculated that the routine practice of checking gastric residuals prior to enteral bolus feeding in VLBW infants was a potentially unnecessary procedure and might be harmful. Therefore, they proposed a feeding algorithm for preterm infants, and randomized studies are currently underway to evaluate their presumption.1 We are expecting the results of their studies and hope that these could clarify the effect of not performing routine evaluation of gastric residuals prior to enteral bolus feeding in VLBW infants. However, we have two concerns with their feeding algorithm. Firstly, we are concerned about the pathway in the algorithm in which a preterm infant has the abnormal abdominal finding (including abdominal distension/emesis/ discoloration/tenderness) but without the radiographic finding (including gasless/pneumatosis/fixed dilated loops/ileus/free air). They intend to evaluate the feeding tolerance by observing the abdominal findings instead of evaluating the gastric residuals. They define feeding intolerance as having abnormal abdominal findings. However, the abdominal findings, including abdominal distension and emesis, are the most typical initial signs and symptoms of necrotizing enterocolitis (NEC) in a preterm infant.2 Symptoms may progress rapidly, often within hours, from subtle signs to abdominal discoloration, intestinal perforation, and peritonitis. Early radiographic findings that should raise the suspicion of NEC include gasless abdomen, dilated bowel loops, and fixed dilated bowel loops on repeated examination. The diagnostic findings are a pneumatosis intestinalis, portal venous gas, or both. Indeed, we wonder whether there may be a preterm infant who has the abdominal findings described in the algorithm but without the above mentioned
radiographic findings. To resume feeding to preterm infants with these abnormal abdominal findings just because of the presumption of negative radiographic findings without considering the other physical conditions including vital signs and other laboratory data (especially white blood cell and platelet counts) is an inappropriate policy that may render the infants to high risk of advanced NEC. Severe NEC requiring surgical intervention can develop in infants even though pneumatosis intestinalis or portal gas has not been detected on the radiograph. These infants may only have abdominal distention without pneumatosis intestinalis.3 Secondly, it is necessary to consider the preterm infants to have feeding intolerance if they present with abnormal abdominal findings, characteristic radiographic findings, and >50% of previous feeding volume or bilious/blood gastric residuals and to treat them as NEC in their algorithm. However, the algorithm did not cover how to manage infants with feeding intolerance, defined by the authors as having abnormal abdominal findings, who have neither >50% of previous feeding volume nor bilious or blood gastric residuals. Previous studies reported by Mihatsch et al, Cobb et al, and Bertino et al did not reach a consensus on the cut-off values of gastric residuals volume or on the color of gastric residuals as diagnostic criteria for NEC. Due to the fulminant nature of NEC, it is necessary to be meticulous in implementing an enteral feeding strategy as described in the proposed feeding algorithm for preterm infants.
Conflicts of interest The authors declare no conflicts of interest.
References 1. Li YF, Lin HC, Torrazza RM, Parker L, Talaga E, Neu J. Gastric residual evaluation in preterm neonates: a useful
http://dx.doi.org/10.1016/j.pedneo.2014.10.005 1875-9572/Copyright ª 2014, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. All rights reserved.
Letter to the Editor
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monitoring technique or a hindrance? Pediatr Neonatol 2014; 55:335e40. 2. Neu J, Walker WA. Necrotizing enterocolitis. N Eng J Med 2011; 364:255e64. 3. Epelman M, Daneman A, Navarro OM, Morag I, Moore AM, Kim JH, et al. Necrotizing enterocolitis: review of state-of-theart imaging findings with pathologic correlation. Radiographics 2007;27:285e305.
Bai-Horng Su* Hsiang-Yu Lin Fu-Kuei Huang Ming-Luen Tsai
Department of Pediatrics, Children’s Hospital of China Medical University, Taichung, Taiwan Department of Pediatrics, School of Medicine, China Medical University, Taichung, Taiwan *Corresponding author. Department of Pediatrics, Children’s Hospital of China Medical University, 2, Yuh-Der Road, Taichung, 404, Taiwan. E-mail address: [email protected] (B.-H. Su) Aug 24, 2014
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.pediatr-neonatol.com
LETTER TO THE EDITOR
Gastric Residuals, Feeding Intolerance, and Necrotizing Enterocolitis in Preterm Infants To the Editor, We read with interest the recent review article by Yue-Feng Li et al 1, describing the correlation between the gastric emptying, gastric residuals, and feeding intolerance in very low birth weight (VLBW) infants. They speculated that the routine practice of checking gastric residuals prior to enteral bolus feeding in VLBW infants was a potentially unnecessary procedure and might be harmful. Therefore, they proposed a feeding algorithm for preterm infants, and randomized studies are currently underway to evaluate their presumption.1 We are expecting the results of their studies and hope that these could clarify the effect of not performing routine evaluation of gastric residuals prior to enteral bolus feeding in VLBW infants. However, we have two concerns with their feeding algorithm. Firstly, we are concerned about the pathway in the algorithm in which a preterm infant has the abnormal abdominal finding (including abdominal distension/emesis/ discoloration/tenderness) but without the radiographic finding (including gasless/pneumatosis/fixed dilated loops/ileus/free air). They intend to evaluate the feeding tolerance by observing the abdominal findings instead of evaluating the gastric residuals. They define feeding intolerance as having abnormal abdominal findings. However, the abdominal findings, including abdominal distension and emesis, are the most typical initial signs and symptoms of necrotizing enterocolitis (NEC) in a preterm infant.2 Symptoms may progress rapidly, often within hours, from subtle signs to abdominal discoloration, intestinal perforation, and peritonitis. Early radiographic findings that should raise the suspicion of NEC include gasless abdomen, dilated bowel loops, and fixed dilated bowel loops on repeated examination. The diagnostic findings are a pneumatosis intestinalis, portal venous gas, or both. Indeed, we wonder whether there may be a preterm infant who has the abdominal findings described in the algorithm but without the above mentioned
radiographic findings. To resume feeding to preterm infants with these abnormal abdominal findings just because of the presumption of negative radiographic findings without considering the other physical conditions including vital signs and other laboratory data (especially white blood cell and platelet counts) is an inappropriate policy that may render the infants to high risk of advanced NEC. Severe NEC requiring surgical intervention can develop in infants even though pneumatosis intestinalis or portal gas has not been detected on the radiograph. These infants may only have abdominal distention without pneumatosis intestinalis.3 Secondly, it is necessary to consider the preterm infants to have feeding intolerance if they present with abnormal abdominal findings, characteristic radiographic findings, and >50% of previous feeding volume or bilious/blood gastric residuals and to treat them as NEC in their algorithm. However, the algorithm did not cover how to manage infants with feeding intolerance, defined by the authors as having abnormal abdominal findings, who have neither >50% of previous feeding volume nor bilious or blood gastric residuals. Previous studies reported by Mihatsch et al, Cobb et al, and Bertino et al did not reach a consensus on the cut-off values of gastric residuals volume or on the color of gastric residuals as diagnostic criteria for NEC. Due to the fulminant nature of NEC, it is necessary to be meticulous in implementing an enteral feeding strategy as described in the proposed feeding algorithm for preterm infants.
Conflicts of interest The authors declare no conflicts of interest.
References 1. Li YF, Lin HC, Torrazza RM, Parker L, Talaga E, Neu J. Gastric residual evaluation in preterm neonates: a useful
http://dx.doi.org/10.1016/j.pedneo.2014.10.005 1875-9572/Copyright ª 2014, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. All rights reserved.
Letter to the Editor
137
monitoring technique or a hindrance? Pediatr Neonatol 2014; 55:335e40. 2. Neu J, Walker WA. Necrotizing enterocolitis. N Eng J Med 2011; 364:255e64. 3. Epelman M, Daneman A, Navarro OM, Morag I, Moore AM, Kim JH, et al. Necrotizing enterocolitis: review of state-of-theart imaging findings with pathologic correlation. Radiographics 2007;27:285e305.
Bai-Horng Su* Hsiang-Yu Lin Fu-Kuei Huang Ming-Luen Tsai
Department of Pediatrics, Children’s Hospital of China Medical University, Taichung, Taiwan Department of Pediatrics, School of Medicine, China Medical University, Taichung, Taiwan *Corresponding author. Department of Pediatrics, Children’s Hospital of China Medical University, 2, Yuh-Der Road, Taichung, 404, Taiwan. E-mail address: [email protected] (B.-H. Su) Aug 24, 2014
