Nutritional outcomes in surgical neonates after hospital discharge

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We read with great interest the article of Kronfli et al. [1] reporting outcomes in neonates with intestinal atresia and gastroschisis. However, despite noting the wide variation in patient outcomes, they did not provide any long-term follow-up data or post-discharge information. Although it is known that neonates requiring major gastrointestinal surgery often have suboptimal early nutrition and prolonged hospitalization with subsequent reduced growth and impaired neurodevelopment [2, 3], there is little information available on the nutritional outcomes and growth of surgical neonates after hospital discharge [4]. We retrospectively evaluated inpatient and outpatient nutritional outcomes in a neonatal cohort who underwent major gastrointestinal surgery over an 18-month period in a tertiary surgical center. 80 eligible babies were identified, with data available for 75%. Only 6 (10%) were in-born. The main surgical diagnoses were necrotizing enterocolitis (NEC) (n = 17, 28%), gastroschisis (n = 8, 13%) and esophageal abnormalities (n = 7, 12%). Stoma formation was required in 28% (n = 17), mostly after NEC (n = 10, 59%). Data were collected until their second birthday, including: clinical details, birth weight, dietetic involvement, medications and milk formulae used and number of outpatient visits. Serial weights preand post-discharge were plotted on appropriate preterm growth charts. Diagnosis-specific trends existed (Fig. 1). Compared to other surgical neonates: those with corrected esophageal abnormalities were significantly more likely to be on antireflux medication (p 0.04); those surgically treated for NEC were at higher risk of failure to thrive (FTT) (p 0.01), both as an inpatient (p \ 0.01) and outpatient (p \ 0.01), and had more outpatient milk changes (p \ 0.01); neonates with stomas had a significantly increased risk of FTT than those without (p \ 0.01) and had more formula milk changes (53 vs. 27%, p 0.07) and dietician referrals (47 vs. 22%). Most neonates (n = 53, 88%) had discharge weights below the 50th centile. Although there was no significant correlation between discharge centile and outpatient FTT (p 1.0), significantly more milk changes occurred in neonates with discharge weights below the 9th centile (p \ 0.01) with no milk changes in those weighing above the 25th centile. One-third of neonates failed to thrive, approximately half (47%) after discharge. Except in the subgroups with stomas or previous NEC, FTT was difficult to predict. Referral rates to dietetic services were inadequate, with only 66% (n = 6) of babies with community FTT being referred. Of those seen by the dietetic service, most (n = 8, 66%) needed a single appointment only, so a more proactive referral service would be unlikely to significantly deplete dietetic resources. Neurodevelopmental data was unavailable for over 90% of neonates, despite the high risk [2–4], highlighting the importance of all teams, including surgical, understanding the value of neurodevelopmental assessment and monitoring. In summary, surgical neonates are at high risk of suboptimal nutrition even after discharge from hospital and we advise opportunistic weighing of these neonates at every outpatient appointment, including in surgical clinics, to allow early detection of growth problems. L. C. Winckworth (&) S.-L. Chuang Department of Neonatology, Chelsea and Westminster NHS Foundation Trust, London, UK e-mail: lucinda.w@doctors.net.uk