Full Oral Feeding Research Articles

“Total Gastric Dissociation (TGD)” in Difficult Clinical Situations

Since the first report by Bianchi in 1997, TOGD has been found to be safe and effective in patients with gastro-oesophageal reflux (GOR) with neurological impairment. This paper explores the versatility of total gastric dissociation (TGD) in difficult clinical situations. The medical records of 11 neurologically normal children treated with TGD and gastrostomy after failure of conventional procedures between 1999 and 2004 were reviewed with respect to demographic data, initial diagnosis, previous operations, postoperative complications, feeding pattern, and follow-up. There were 7 males and 4 females. The mean age at operation was 52.7 months (24 to 72 m). The indications were severe colo-oesophageal reflux in 3; 1 post-fundoplication necrotic stomach; 1 gastric remnant after subtotal gastrectomy for bleeding; 1 microgastria; 2 with severe oesophageal obstruction following repeated failed repair of congenital stenosis of the oesophagus and after fundoplication; 1 congenital short oesophagus with left-sided congenital diaphragmatic hernia; and 2 with severe dysfunctional oesophagus following repair of congenital tracheo-oesophageal cleft. Full oral or gastrostomy feeding was established by the 5th postoperative day. The average follow-up was 47.2 months (24-72 months). There were 4 late deaths in the group: 2 with respiratory failure, 1 with sepsis secondary to peritonitis (small bowel herniation into the thorax) and 1 with pneumococcal infection. Seven patients are alive and thriving with markedly reduced episodes of chest infections and hospitalizations. In this study TGD presented with no peri-operative morbidity and mortality and had good long-term results. The procedure offers a safe alternative for neurologically normal children after the failure of conventional surgical procedures.

Re: Second‐trimester intra‐abdominal bowel dilation in fetuses with gastroschisis predicts neonatal bowel atresia

It was with great interest that we read the article by Nick et al.1 in a recent issue of the Journal. Similar results were published in our article, ‘Surveillance and outcome of fetuses with gastroschisis’2, and we strongly support the repeat findings by Nick et al., that intra-abdominal bowel dilatation is associated with bowel obstruction. In our paper2, comprising 64 fetuses with a prenatal diagnosis of gastroschisis, five fetuses had intra-abdominal dilatation of the bowel and all had bowel obstruction. These findings were also discussed extensively and images shown during an oral presentation at the ISUOG World Congress in New York in 20023. In the years following our publication2, studying 30 additional fetuses with gastroschisis, we have found further evidence that intra-abdominal bowel dilatation is a reliable marker for intestinal obstruction. Of these 30 fetuses, only one of those without intra-abdominal dilatation had bowel obstruction postnatally. Consequently, we rely on our ultrasound findings concerning the appearance of the fetal bowel when counseling the parents, and have done so for several years. In addition, the pediatric surgeons at our hospital are well aware of the reliability of these prenatal findings and use them to plan for the expected surgery. However, we have not found the outcome in terms of survival to be worse for the infants with bowel obstructions/atresias. The immediate morbidity in terms of hospitalization and time to full oral feeding is longer, but we have not observed any effect on the survival rate. In this context, we also want to emphasize the importance of delayed definitive bowel surgery following primary reduction en bloc in cases with massive peel and possible atresias, as we also discussed in our article2. In addition, it is important to note that a late developing intra-abdominal bowel dilatation may be associated with ‘closing gastroschisis’4, a rare, and if not handled correctly, fatal, complication. A. Brantberg*, H.-G. Blaas*, S. E. Haugen , S. H. Eik-Nes*, * National Center for Fetal Medicine, Department of Obstetrics and Gynecology, Norway, Department of Pediatric Surgery, St Olavs Hospital, Trondheim University Hospital, NO-7006 Trondheim, Norway

Treatment strategies in the management of jejunoileal and colonic atresia

<b>BACKGROUND/PURPOSE:</b> The purpose of this prospective study was to review the operative findings, treatment strategies, as well as the results of management of 46 consecutive cases of jejunoileal and colonic atresia, managed over a 2-year period.<br><b> MATERIALS AND METHODS:</b> There were 42 patients with jejunoileal atresia (JIA) and 4 with colonic atresia (CA). The 4 group types were: type I-membranous (n=20), type II- blind ends separated by a fibrous cord (n=6), type IIIa- blind ends with a V-shaped mesenteric defect (n=10), type IIIb- apple-peel atresia (n=4) and type IV- multiple atresias (n=6). Primary surgery for JIA consisted of resection with a single anastomosis (n=37), anastomosis after tapering jejunoplasty (n=3), multiple anastomosis (n=1) and a Bishop-Koop ileostomy (n=1). For CA, resection with primary anastomosis was performed. A single end-to-oblique anastomosis after adequate resection of dilated proximal bowel, was the preferred surgical procedure. In the absence of facilities for administering TPN, early oral/nasogastric (NG) tube feeding was encouraged. In patients with anastomotic dysfunction, conservative treatment of the obstruction followed after its resolution by gradually increased NG feeds, was the preferred treatment protocol. <br><b> RESULTS:</b> Late presentation or diagnosis with hypovolemia, electrolyte imbalance, unconjugated hyperbilirubinemia (n=25) and sepsis (n=6), were significant preoperative findings. After resection and anastomosis, significant shortening of bowel length was seen in 16 patients (34.7%). Postoperative complications included an anastomotic leak (n=3), a perforation proximal to the anastomosis in 1 and anastomotic dysfunction in 5 patients. Full oral or NG tube feeding was possible only by the 13th to 31st postoperative day (POD), after the primary surgery in patients with anastomotic dysfunction and those undergoing reoperation. Overall, 38 patients survived (82.6%). Mortality was highest in patients with type IIIb or type IV JIA.<br><b> CONCLUSIONS:</b> Despite lack of ideal facilities for neonatal intensive care and administration of TPN, good results were achieved in the management of JIA and CA by following these principles: (1) adequate preoperative resuscitation, (2) meticulous surgical technique and a standardized surgical protocol, (3) early recognition of postoperative complications and their management by a uniform protocol and (4) wherever possible, early institution of oral or NG feeds, preferably by breast milk.<br>

Consequences of Delayed Surgical Closure of Patent Ductus Arteriosus in Very Premature Infants

Surgical closure of ductus arteriosus is commonly indicated in premature newborns. The aim of this study was to assess short-term and mid-term effects of delayed surgical closure of the ductus arteriosus on respiratory and digestive outcome in extremely preterm infants. We retrospectively studied 58 infants less than 28 weeks gestational age who underwent surgical closure of ductus arteriosus between January 1997 and December 2002. Nine infants with intrauterine growth restriction and major congenital malformation were excluded from the study. Criteria for surgical closure of ductus arteriosus were: (1) medical treatment failure (ie, indomethacin or ibuprofen) and (2) hemodynamically patent ductus arteriosus: systemic arterial pressure less than gestational age in mm Hg, heart failure, left atrial-aortic root ratio greater than 1.6, mean velocity in the left pulmonary artery greater than 0.6 m/s, and ductus arteriosus diameter greater than 3 mm. Infants were divided into two groups: (1) the early group who had surgery before 21 days of life (n = 31), and (2) the late group who had surgery after 21 days of life (n = 27). Preoperative and postoperative criteria were compared between the two groups (ie, gestational age, birth weight, hemodynamic, ventilatory, and echographic [left atrial-aortic root ratio, mean velocity in the left pulmonary artery] parameters). Preoperative gestational age and birth weight did not differ between the two groups. In the early group, gestational age was 26 weeks (range, 23 to 28 weeks and birth weight was 800 g (range, 630 to 1,240 g). In the late group, gestational age was 26 weeks (range, 24 to 28 weeks) and birth weight was 840 g (530 to 1,130 g). Hemodynamic, ventilatory, and echographic parameters were similar in both groups. Rate of bronchopulmonary dysplasia was similar in both groups. However, at 24 hours post surgery, median FiO2 was higher in the late group (28% [range, 21% to 65%]) than in early group (21% [range, 21% to 60%]) (p < 0.05). Furthermore, full oral feeding was acquired later in the late group (57 days of life [range, 30 to 136 days]) than in the early group (37 days of life [range, 27 to 84 days]) (p < 0.01), and body weight at 36 weeks of post-conceptional age was higher in the early group at 1,800 g (range, 1,250 to 2,750 g) than in the late group at 1,607 g (1,274 to 2,200 g) (p < 0.05). Our findings show that early surgical closure of the ductus arteriosus (< 3 weeks of life) is associated with shortened delay for full oral feeding and improved body growth when compared with late surgical closure (> 3 weeks of life).

Antroduodenal Motility and Feeding Outcome among Neonatal Extracorporeal Membrane Oxygenation Survivors

Feeding difficulties are common among survivors of extracorporeal membrane oxygenation (ECMO). In this study, we characterized antroduodenal motor patterns and feeding outcomes among 10 ECMO survivors. Intestinal motor patterns were recorded in 10 ECMO survivors within 48 hours of the initiation of enteral feeding. Subsequent feeding outcomes were tracked until discharge. We compared the motor patterns of infants achieving full oral feedings by 1 month postnatal age with those who did not achieve full oral feedings by 1 month postnatal age. In infants failing to achieve full oral feedings, duodenal clusters occupied less of the total record (P < 0.05), and clusters had significantly lower amplitude (P < 0.05) than were seen in successful infants. Infants failing to achieve full oral feedings had greater time spent in motor quiescence (P < 0.05) than successful infants. Neither group had migrating motor complexes during fasting or mature duodenal motor responses to feeding. At discharge, six infants with feeding failure were more likely to require tube feeding, and the hospital stay was 3.6 times longer. Intracranial abnormalities were detected by computed tomography scan in five of six infants with feeding failure. Early intestinal dysmotility in infants surviving ECMO is associated with later feeding difficulties and prolonged hospitalization.

Heart Rate Variability and Feeding Bradycardia in Healthy Preterm Infants During Transition From Gavage to Oral Feeding

Healthy preterm infants, 32 to younger than 34 weeks postconceptional age, (n = 81) were randomly assigned to standard care or semidemand protocols for making the transition from gavage to oral feeding. Experimental infants showed less autonomic arousal (decreased low-frequency [LF] and decreased high-frequency [HF] power) when using a pacifier before feeding compared with control infants. During oral feeding, control infants showed an increase in the sympathetic to parasympathetic balance (LF/HF) from the prefeeding period, whereas LF/HF for experimental infants did not change significantly. In the 48 hours after achieving full oral feeding, control infants had significantly more feeding bradycardia episodes than experimental infants. The semidemand protocol that included use of a pacifier before oral feeding, opportunity to feed orally up to eight times per day, and use of infant behavior to begin and end feedings resulted in the autonomic balance of the experimental infants being more stable as they learned to feed orally.

Implementation and Evaluation of a Home Gavage Program for Preterm Infants

To describe the implementation and evaluation of a home gavage program for preterm infants. Retrospective chart reviews were used to assess the physiologic progress of infants, and retrospective written questionnaires were administered by mail to families participating in home gavage to assess their experience and solicit advice. One hundred forty-three infants born at <37 weeks gestational age with a primary diagnosis of prematurity who met criteria for home gavage, of whom 52 were given home gavage and 91 attained full oral feedings in intensive care before discharge. The safety of home gavage was evaluated by weight change and hospital readmission. Parental satisfaction was assessed by the mailed survey. Cost savings were also evaluated. Infants gained and average of 31 gm/day while receiving home gavage. No hospital readmissions were related to home gavage. Parents expressed satisfaction with the home gavage program. There was an average savings of $12,428 per infant related to shorter hospital stays.

The early feeding skills assessment for preterm infants.

Preterm infants develop the skills necessary to begin oral feeding as their health stabilizes and as they reach a postconceptional age that supports coordination of breathing and swallowing with oral-motor functioning. The time from initiation of oral feeding to full oral feedings (with adequate intake for growth and maintenance of physiologic stability) can vary from days to months for the preterm infant. The approach to feeding the infant during this transition period must be developmentally supportive and tailored to meet the needs of the individual. To accomplish this, caregivers--notably nurses and parents--need to communicate about the specific skills that the infant has gained, about skills that are emerging, and about skills that the infant has not yet developed. The Early Feeding Skills (EFS) Assessment is a checklist for assessing infant readiness for and tolerance of feeding and for profiling the infant's developmental stage regarding specific feeding skills: the abilities to remain engaged in feeding, organize oral-motor functioning, coordinate swallowing with breathing, and maintain physiologic stability. This article introduces the EFS.

Effect of an oral stimulation program on sucking skill maturation of preterm infants

This study assessed the effect of an oral stimulation program on the maturation of sucking skills of preterm infants. Thirty-two preterm infants (13 males, 19 females), appropriate size for gestational age (gestational age at birth 28 wks, SD 1.2wks; birthweight 1002g, SD 251g), were randomly placed into experimental and control groups. The experimental group received a daily 15-minute oral stimulation program, consisting of stroking the peri- and intra-oral structures, for 10 days before the start of oral feedings. Sucking measures were monitored with a specially-designed nipple-bottle apparatus. Results indicate that the experimental group achieved full oral feedings 7 days sooner than the control group, and demonstrated greater overall intake (%), rate of milk transfer (mL/min), and amplitude of the expression component of sucking (mmHg). There was no difference in sucking stage maturation, sucking frequency, and amplitude of the suction component of sucking. Endurance, defined as ability to sustain the same sucking stage, sucking burst duration, and suction and expression amplitudes throughout a feeding session, was not significantly different between the two groups. The stimulation program enhanced the expression component of sucking, resulting in better oral feeding performance.

Comparison of sucking patterns at introduction of oral feeding and at term in Israeli and American preterm infants

It has been hypothesized that early initiation of oral feeding in premature infants may enhance the maturation of sucking patterns. To compare preterm infant sucking characteristics in urban level III neonatal care units in the USA and Israel. The two hospitals have different practices regarding the introduction of oral feeding. Infants were assessed at 34-35 wk postconceptional age (PCA) and at term. Sucking parameters were assessed with the Kron's Nutritive Sucking Apparatus. 70 infants (38 Americans and 32 Israelis) participated in the study. Oral feedings were initiated earlier (32.6 +/- 4.3 vs 34.5 +/- 1.8 wk PCA, p < 0.01) and full oral feedings were reached earlier (35.4 +/- 2.8 vs 36.5 +/- 2.5 wk PCA, p < 0.05) in the USA infants. American preterm infants produced significantly more sucks (p < 0.001), had a higher suck rate (p < 0.001), more sucks per burst (p < 0.05), and a shorter interburst width (p < 0.01) at 34 wk PCA than Israeli infants. At term, American infants produced significant more sucks (p < 0.001), higher suck rate (p < 0.001), shorter intersuck width (p < 0.001), and a shorter interburst width (p < 0.05) than the Israeli infants of the same PCA. Different practices in the care of preterm infants, such as postconceptional age at introduction of oral feeding, may play a role in the development of feeding and feeding organization at term.

Gastroesophageal Reflux in the Preterm Neonate

After completing this article, readers should be able to: 1. Describe the epidemiology and pathophysiology of gastroesophageal reflux (GER) in preterm neonates. 2. Delineate the associations of GER with apnea, chronic lung disease, behavior, and growth of preterm infants. 3. Review the investigations used to evaluate GER in preterm infants. 4. Describe nonpharmacologic and pharmacologic therapies for GER. Gastroesophageal reflux (GER) is a normal physiologic event occurring across the age spectrum. It may contribute to a variety of disorders, including esophagitis, feeding problems, and airway disease in all age groups. (1) A large number of symptoms and signs have been purported to be caused by GER despite a lack of data showing a clear association between a specific symptom and GER. In preterm infants, empiric therapy often is administered using agents of unproven efficacy and safety to treat symptoms that likely are unrelated to GER. In a survey on management practices for GER in preterm infants, common treatment strategies included positioning (98%) and slopes (96%), histamine 2 (H 2) receptor antagonists (100%), feed thickeners (98%), antacids (96%), prokinetics (79%), proton pump inhibitors (PPIs) (65%), and dopamine receptor antagonists (53%). (2)(3) The safety, efficacy, and appropriate dosing recommendations for most medical therapies remain uncertain in neonates. In this review, we attempt to summarize the current literature regarding physiology, pathophysiology, and diagnostic and management strategies for GER pertinent to the neonate, with an emphasis on the preterm infant. GER describes the retrograde movement of stomach contents (air or feeding, liquid or semisolid, acid or alkaline, enzymes or bile salts) into the esophagus. GER disease (GERD) occurs when GER causes symptoms or signs such as pain, poor weight gain, esophagitis, hematemesis, and airway symptoms, including apnea, aspiration, recurrent pneumonia, chronic lung disease (CLD), or large airway inflammation. However, any of these symptoms or signs …

Early enteral feeding in newborn surgical patients

Objective We report the results of a multicenter prospective trial of early enteral trophic feeding in a group of 56 neonates who required abdominal surgery for a variety of congenital anomalies. Methods In this clinical study, 33 neonates were fed in the early postoperative period (early enteral nutrition [EEN] group), and the remaining 23 (control [C] group) were fasted until resolution of postoperative ileus. Patients in the EEN group (Kocaeli feeding protocol) received 3 to 5 mL of breast milk every hour through a nasogastric feeding tube, starting a mean of 12 h (8 to 20 h) after surgery. The nasogastric tube was clamped for 40 min after each infusion and then opened for drainage. Groups were further divided into two subgroups according to whether an intestinal anastomosis or laparotomy was performed. The change in daily gastric drainage, time to first stool, day of toleration to full oral feeding, and length of hospital stay were compared. Blood bilirubin levels, white blood cell count, and C-reactive protein levels were monitored. Results The time to first stool and day of toleration to full oral feeding occurred significantly sooner, whereas nasogastric tube drainage duration and hospital stay were significantly shorter in the EEN-anastomosis group than in the C-anastomosis group. Time to first stool occurred significantly sooner in the EEN-laparotomy group than in the C-laparotomy group, although other parameters did not differ. Neither anastomotic leakage nor dehiscence was observed in any group. There were two cases of wound infection and two of exitus among patients in the C group. Conclusion Postoperative, early intragastric, small-volume breast milk feeding is well tolerated by newborns. It is a reliable and feasible approach in neonates even in the presence of an intestinal anastomosis after abdominal surgery.

The Effect of Oral Feeding Guidelines on the Time to Full Oral Feedings in Premature Infants

The Effect of Oral Feeding Guidelines on the Time to Full Oral Feedings in Premature Infants

Impact of Early and Consistent Occupational Therapy With Preterm Infants' Oral Feedings.

Purpose: This study was designed to assess the effectiveness of early occupational therapy intervention on preterm infant's ability to achieve full oral feedings and be discharged from the neonatal intensive care unit. Study design and methods: Forty-one preterm infants were randomized to receive occupational therapy intervention or sham intervention beginning at 30 weeks' gestational age. An oral stimulation and therapeutic feeding protocol was used for those infants in the experimental group. Sham intervention was used for the infants in the control group and included holding the infant without any provision of oral stimulation or therapeutic feedings. These interventions were provided three times a week for 10–15 minutes each. Outcome measures included: postmenstrual age at first successful feeding, postmenstrual age at full oral feedings, number of infants receiving occupational therapy consultations, postmenstrual age at discharge from neonatal intensive care unit, and total length of hospital stay. Results: No significant differences were found in the aggregate; however, significant differences were found in the subgroup of less then 29 weeks' gestational age. Extremely preterm infants receiving early occupational therapy achieved full oral feedings on average 2.3 weeks earlier than their control counterparts. Conclusion: Early limited occupational therapy intervention may accelerate time to full oral feeding in extremely preterm infants.

State of the Science

Finding ways to consistently prepare preterm infants and their families for more timely discharge must continue as a focus for everyone involved in the care of these infants in the neonatal intensive care unit. The gold standards for discharge from the neonatal intensive care unit are physiologic stability (especially respiratory stability), consistent weight gain, and successful oral feeding, usually from a bottle. Successful bottle-feeding is considered the most complex task of infancy. Fostering successful oral feeding in preterm infants requires consistently high levels of skilled nursing care, which must begin with accurate assessment of feeding readiness and thoughtful progression to full oral feeding. This comprehensive review of the literature provides an overview of the state of the science related to feeding readiness and progression in the preterm infant. The theoretical foundation for feeding readiness and factors that appear to affect bottle-feeding readiness, progression, and success are presented in this article.

Regional Neonatal Oral Feeding Protocol

The Calgary Health Region Neonatal Oral Feeding Protocol is the culminating work of a broad range of healthcare professionals, including staff nurses, nurse practitioners, nurse educators, nurse managers, dietitians, lactation consultants, clinical nurse specialists, and occupational therapists. The protocol represents a synthesis of research evidence and expert opinion pertaining to the introduction and management of oral milk feedings for high-risk infants in the neonatal intensive care unit. This evidence-based neonatal oral feeding protocol is presented to share knowledge and skill required to create positive feeding experiences while assisting high-risk infants to achieve full oral feedings. Goals of this project include promoting consistent neonatal nursing feeding practices and changing the ethos in relation to feeding interactions between caregiver and infant in the neonatal intensive care unit. This culture change will assist nurses to identify what is unique about their professional practice, which is of particular importance given the skill mix resulting from hospital understaffing and a growing nursing workforce shortage.

The Santulli enterostomy in necrotising enterocolitis.

An ideal operation for necrotising enterocolitis (NEC) would be quick and reliable, remove all nonviable bowel, minimise the loss of intestinal length, permit early restoration of intestinal continuity, and minimise the need for secondary operations. No operation currently meets all these needs. In this study we review our experience with the Santulli enterostomy in NEC. From 1992 to 1998, 19 patients (16 males, three females) underwent a Santulli enterostomy for Bell grade III NEC. The median gestational age at birth (GA) was 26 weeks (range 23-30), and the median birth weight 755 g (range 600-1095). The median patient age at operation was 10 days (range 3-59), and the median operative time was 55 min (range 25-90). Sixteen (84%) patients survived. Complications included leakage of the Santulli anastomosis in four cases, stomal necrosis in two cases, additional intestinal necrosis in two cases, leakage of a concurrent intra-abdominal anastomosis in two cases, and intestinal obstruction in four cases. Twelve patients underwent relaparotomy. Enteral feeding was started at a median of 5 days postoperatively (range 2-9), with full oral feeding possible at a median of 21 days (range 10-128). The median time until closure of the enterostomy was 48 days and the median hospital stay 87 days (range 19-197). After stomal closure, obstructive symptoms necessitated a new Santulli enterostomy in two patients and a revision of the anastomosis in one patient. Santulli enterostomy can be used to treat NEC even in very small premature babies. It enables rapid recovery of intestinal continuity and early stomal closure. However, the operation is technically demanding and carries significant morbidity.

Management of ventral hernia after giant exomphalos with external pressure compression using helmet device

Purpose The aim of this study was to evaluate an alternative technique of reducing a ventral hernia that follows the primary conservative treatment of a giant omphalocoele. Methods The patient is a full-term male neonate with a giant exomphalos. Initially triple dye was applied as an eschar-inducing agent. This resulted in a ventral hernia after 1 month. It was decided to achieve expansion of the abdominal cavity based on the principle of external pressure compression using a sphygmomanometer cuff over the hernia. The cuff was worn continuously, and manual pressure was applied daily. Care was taken to avoid intraabdominal hypertension using the reading of the manometer that was attached. The external pressure was corroborated with observations of respiration and circulation. Results The child did not show any ill effects of raised intraabdominal pressure. Throughout the treatment, the child was on full oral feedings and did not require any ventilator support. Reduction of the ventral hernia was achieved in 9 months. Surgical repair of the residual hernia defect was carried out by double breasting of the fascia. Conclusions The application of controlled external pressure using a specially constructed device is a safe, noninvasive, and effective method of achieving reduction of a ventral hernia after primary conservative treatment of a giant omphalocoele.

P0938 NATURAL HISTORY OF ORAL FEEDING BEHAVIOR IN INFANTS BORN AT LESS THAN 30 WEEKS GESTATION

Introduction: Full oral feeding (FOF) is a prerequisite for hospital discharge of the preterm infant. However, infants born at <30 weeks (wks) gestational age (GA) may be at risk for dysfunctional swallow and GE reflux leading to persistent chronic lung disease, apnea with hypoxic episodes, or food refusal, all of which prolong hospitalization and increase parent anxiety. Objective: We hypothesized that infants born at <25 wks versus >25 wks GA, or those with oxygen (O2) requirements at 36 wks postmenstrual age (PMA) would be less likely to achieve FOF by 42 wks PMA. Methods: A 45-month retrospective review was performed of 101 infants born at or transported to Johns Hopkins Hospital and transferred to Mt. Washington Pediatric Hospital when stable. We determined the PMA that infants <30 wks GA reached FOF and the effect of other covariates on this outcome. Kaplan-Meier (K-M) graphs were constructed to estimate the probability of failure to reach FOF by 54 wks PMA with/without O2 requirements at 36 wks PMA. Results: Gastrostomy tubes (GT) were required for 11 infants, all born at 26 wks. Between 23–30 wks GA, the chance of achieving FOF increased by 25% for each additional wk of gestation. K-M graphs estimated the probability of achieving FOF by 54 wks PMA to be 0.6, 0.80, and 0.98 in infants born <25 wks, 25–28 wks, and >28 wks, respectively (P<0.05). Also, the chance of failing to achieve FOF was 68% greater for infants needing O2 at 36 wks PMA. Of infants born <25 wks, 30% did not achieve FOF by 43 wks PMA, with 23% requiring GT placement.Table 1: Percent of infants (95% confidence level) at each PMA that acheived FOFConclusion: The success of preterm infants achieving FOF by discharge is inversely related to GA. Approximately one-third of infants <25 wks do not achieve FOF by 43 wks PMA. Furthermore, O2 dependence at 36 wks PMA significantly increases the chance of FOF failure. Delayed or unsuccessful oral feeding in extremely premature infants significantly impacts length of stay, discharge planning and parent education.

Endoscopic Management of Duodenal Webs in Infants

Duodenal atresia and stenosis are rare causes of intestinal obstruction in the newborn with the prevalence of 1:6000. Intrinsic duodenal obstruction typically involves the second portion of the duodenum and occurs as a result of several embryologic defects in foregut development, canalization, or rotation. We report two cases of duodenal obstruction in infants successfully treated endoscopically. A comprehensive 32-year single center experience reported 138 newborns and infants presenting with symptoms of vomiting, abdominal distention, dehydration, and weight loss. Patient 1, a two-month-old neonate presents with vomiting. An upper G I series revealed a dilated proximal duodeneum, with an obstructing web. The adult upper endoscope, (O.D. 9.4 mm) was passed into the stomach. Endoscopy revealed a membranous web-like obstruction with a central 2 mm orifice (Fig. 1B). The delicate diaphragm-like movement demonstrated a membranous web. A sphincterotome was passed over the guidewire and three radial incisions were made. Feeding was resumed and the patient discharged after 24 hours. At 12 months, the patient was tolerating full oral feedings and thriving. Patient 2 was a 7 month old male infant with chronic regurgitation and poor weight gain. Upper GI series demonstrated web-like stenosis or membranous stricture. An upper adult endoscope was passed into the stomach. Endoscopy revealed a dilated first portion of the duodenum with a 3 mm opening. A through-the-scope (TTS) dilation balloon was passed through the scope over a wire through the orifice. The orifice was dilated to 10mm (Fig. 2C). A sphictertome was passed over a wire and two radial cuts were made at 11 and 1 o clock (Fig. 2D). The patient was discharged after 24 hours. At the 9-month follow-up, the patient was doing well with excellent oral intake and weight gain. Endoscopic, non-surgical therapy of non-atretic lesions provides an effective, non-invasive management of duodenal webs and stenosis in pediatric patients. The endoscopic procedure avoids the morbidity associated with surgical duodenotomies, allows for prompt feeding and early hospital discharge.