Effect of Gastric Residual Evaluation on Enteral Intake in Extremely Preterm Infants: A Randomized Clinical Trial

Abstract

Importance: Evaluating prefeed gastric residuals is considered routine care but has little supporting evidence.

Objective: To determine the effect of omitting prefeed gastric residual evaluation on nutritional outcomes in extremely preterm infants.

Design, setting, and participants: This single-center randomized clinical trial compared the omission of gastric residual evaluation with prefeed gastric residual evaluation. Infants were recruited from a level 4 neonatal intensive care unit and were enrolled from October 17, 2013, to October 8, 2016, and then followed up for 6 weeks after birth. Eligible participants were infants born at 32 or fewer weeks' gestation with a birth weight of 1250 g or less; they were enrolled within 72 hours after birth and within 24 hours after feeding initiation. All participants (N = 143) were included in the modified intent-to-treat analysis, which was conducted from March to July 2018.

Interventions: The residual group underwent prefeed gastric residual evaluation; the no residual group did not. Feeding decisions were made according to nutritional guidelines, and infants received only human milk.

Main outcomes and measures: The primary outcome was weekly enteral nutrition intake in mL/kg for 6 weeks after birth.

Results: Of 143 infants, 74 (51.7%) were randomized to undergo gastric residual evaluation (residual group) and 69 (48.3%) to omitted gastric residual evaluation (no residual group). The residual group comprised an even number of male and female infants (37 [50.0%]) with a mean (SD) gestational age of 27.1 (2.4) weeks and a mean (SD) birth weight of 888.8 (206.6) grams, whereas the no residual group had more male infants (36 [52.17%]), a mean (SD) gestational age of 27 (1.2) weeks, and a mean (SD) birth weight of 915.2 (180) grams. The no residual group had feedings that advanced more quickly compared with the residual group (mean weekly increase, 20.7 mL/kg/d vs 17.9 mL/kg/d; P = .02) and consumed more feedings at weeks 5 (137.2 [95% CI, 128.6-145.8]; P = .03) and 6 (141.6 [95% CI, 133.2-150.0]; P = .03). Among the secondary outcomes, the no residual group had higher mean estimated log weights (7.01 [95% CI, 6.99-7.02] vs 6.98 [95% CI, 6.97-7.00]; P = .03), had fewer episodes of abdominal distention (0.59 [95% CI, 0.34-1.01] vs 1.79 [95% CI, 1.27-2.53]; P = .001), and were discharged 8 days earlier (4.21 [95% CI, 4.14-4.28] vs 4.28 [95% CI, 4.19-4.36]; P = .01). Odds for necrotizing enterocolitis (0.058 [95% CI, 0.018-0.190] vs 0.026 [95% CI, 0.006-0.109]), death (0.004 [95% CI, 0.0003-0.046] vs 0.012 [95% CI, 0.001-0.131]), late-onset sepsis (0.970 [95% CI, 0.67-1.40] vs 1.38 [95% CI, 0.97-1.94]), and ventilator-associated pneumonia (0.084 [95% CI, 0.033-0.214] vs 0.056 [95% CI, 0.019-0.168]) were similar between groups.

Conclusions and relevance: Among extremely preterm infants, the omission of gastric residual evaluation increased the delivery of enteral nutrition as well as improved weight gain and led to earlier hospital discharge; these results may translate into evidence-based practice.

Trial registration: ClinicalTrials.gov identifier: NCT01863043.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Parker reported receiving grants from the National Institutes of Health (NIH) during the conduct of the study. Dr Weaver reported receiving grants from the NIH during the conduct of the study. Dr Shuster reported receiving grants from the NIH during the conduct of the study. Dr Krueger reported receiving grants from NIH during conduct of this study. Dr Neu reported receiving grants from the NIH during the conduct of the study and from Infant Bacterial Therapeutics outside of the submitted work. No other disclosures were reported.

Figures

Figure.. Consort Diagram

NEC indicates necrotizing enterocolitis; SIP, spontaneous intestinal perforation.