Refeeding gastric residuals in extremely preterm infants.

Abstract

Commentary on: Salas AA, Cuna A, Bhat R, McGwin G Jr, Carlo WA, Ambalavanan N. A randomised trial of refeeding gastric residuals in preterm infants. Arch Dis Child Fetal Neonatal Ed 2015; 100: F224–8. doi:10.1136/archdischild-2014-307067. Salas et al. 1 tackle a common clinical problem: what should you do when significant gastric contents are aspirated before feeding an extremely preterm infant? Gastric residuals could be an early sign of NEC and may call for caution on refeeding. On the other hand, discarding gastric residuals may impair digestion and delay full enteral feeds. There is no evidence to support either approach, especially in the high-risk (for both NEC and undernutrition) group of extremely preterm infants. Although Salas et al. 1 is to be congratulated for their attempt to resolve this issue, the most important drawback is that conclusions – regarding both efficacy and safety – suffer from some limitations. For the primary question ‘Does refeeding of gastric residuals reduce time needed to achieve full enteral feedings?’, the authors conclude that the answer is no. However, although intention-to-treat analysis was used, the primary efficacy end point was only possible to assess in 59 infants, as the estimated sample size (n = 72) was not reached. Therefore, there are two possibilities: either the study may have been underpowered (p = 0.11 for a group difference in primary outcome) or the results rightly disprove the hypothesis for an effect size of 2-day difference or more to achieve full feeds (whether this desired group difference was based on pilot data or represents a consensual view of what would be the minimal clinically significant difference is not known). Also, and as pointed out by the authors, numbers were too small to draw any firm conclusions about safety. Information on the volumes of gastric residuals was lacking, and such information would have helped interpretation. Finally, donor milk 2 was not offered, possibly contributing to quite high rates of intestinal perforation, surgical necrotising enterocolitis or death. So what should the clinician do? Previous studies in ELBW infants (<1000 g) have demonstrated that disregarding of gastric residuals up to 2–3 mL (even if they were greenish) did not increase the risk for NEC 3. Other than that, there seems to be very little evidence. Given the findings by Salas et al. 1, this reviewer agrees with the conclusion that refeeding gastric residual volumes in extremely preterm infants does not seem to reduce time to achieve full enteral feeding and is likely to be safe. The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) suggest that minimal enteral nutrition is initiated within the first 2 days of life and advanced by 30 mL/kg/day in infants ≥1000 g 4. A recent systematic review of studies in VLBW infants (1000–1500 g) came to a similar conclusion: advancing enteral feed volumes at daily increments of 30–40 mL/kg did not increase the risk of NEC, whereas advancing the enteral feeds at slower rates resulted in several days delay in regaining birthweight and establishing full enteral feeds 5. For ELBW infants below 1000 g BW, recommendations are more scarce, most likely reflecting the lack of solid evidence. In Sweden, minimal enteral feeding with breastmilk is – right or wrong – initiated within hours after birth, also in extremely preterm infants. https://ebneo.org/2015/05/re-feeding-gastric-residuals-in-extremely-preterm-infants/ None. None.