Download Gastric Residuals in the Preterm Infant

Running head: GASTRIC RESIDUALS IN THE PRETERM INFANT
Gastric Residuals in the Preterm Infant
Stephanie Nelson, Rachael Niemeyer, Michelle Omdahl, & Lauren Line
Creighton University
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GASTRIC RESIDUALS IN THE PRETERM INFANT
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ABSTRACT
Problem: Preterm infants have an increased susceptibility to feeding intolerance and increased
gastric residuals. With an unknown correlation between feeding intolerance and development of
necrotizing enterocolitis (NEC), emphasis needs to be placed on determining the role of gastric
residuals in hopes of decreasing the adverse outcomes of decreased weight gain and
neurodevelopmental complications. Without clinical guidelines or standards in place, these
infants may be potentially affected by unnecessary delays in feeding advancement, extended
hospital stays, and increased expenses. The providers’ order regarding the gastric residuals may
lead to feeding volume and caloric deficiencies.
Methods: This prospective, exploratory, pilot study included infants weighing less than 1800
grams admitted to Sanford Health Fargo Region NICU and Essentia Health Fargo Region NICU.
The bedside nurse recorded the infant’s birth weight, amount of feedings received, amount of
pre-feed gastric residual obtained, signs of abdominal distension, emesis, or intolerance noted,
and how the provider responded to the residual (refed, discarded, or NPO) on a daily survey at
the patients’ bedside.
Results: Data were collected on 17 infants with a total of 1059 feedings. The number of days
infants were observed varied from 2 to 47. Residuals were not present in 56% of the feedings
recorded. Of the 469 decisions that were made on residuals, 70% were refed the residual and
given an additional full feeding, 20% of residuals were refed and subtracted from the subsequent
feeding, 6% of residuals were discarded with full subsequent feeding, 3% of residuals were refed
with no additional feeding given, and 1% of residuals were discarded with feeding held or the
infant was made NPO. Therefore, 30% of the feedings resulted in a decrease in fluid volume and
nutritional calories.
Conclusions: The routine use of gastric residuals to assess feeding tolerance is common practice
in the NICU. There are some units where measuring gastric residuals are not done. In units
without routine gastric residual evaluation, the infants reached full feedings sooner and have
fewer days of venous access. Providers continue to make decisions based on gastric residuals
that are not evidence-based. The data collected illustrated the vast variety of ways providers
manage gastric residual volumes. Residuals were refed, discarded, or subtracted even when
there were no other symptoms of feeding intolerance. This information supports the need for
further research regarding gastric residuals and how to best manage the information we obtain
when checking a residual.
GASTRIC RESIDUALS IN THE PRETERM INFANT
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The Use of Gastric Residuals in Neonatal Intensive Care Units
Premature birth, at less than 37 weeks gestation, continues to be the leading cause of
perinatal morbidity and mortality in developed countries with an increase in industrialized
countries (Goldenberg, Culhane, Iams, & Romero, 2009). There are multiple causes for preterm
birth, some of which include maternal or fetal indications for delivery, spontaneous preterm
labor and, premature rupture of membranes. In addition, physical complications such as
infection, adverse behaviors, and placental insufficiency play a role. The increase in premature
birth rate can be attributed to the increase in reproductive medicine resulting in multiple
pregnancies (twins, triplets, etc) (Goldenberg et al., 2009). Incidence of premature birth rates
varies from 6-15% (Arzuago & Meadows, 2014).
As medical technology has continued to advance, the survival rate of these preterm
infants has increased from 15% to 75% over the last twenty years (Gregory & Connolly, 2012).
With the increase in preterm survival has come the issue of when to begin enteral nutrition.
Initiating early enteral nutrition in preterm infants not only plays a significant role in growth and
development in infancy and childhood, it can also prevent many of the co-morbidities in the
neonatal period (Gregory & Connolly, 2012).
Management of the nutritional needs of these premature infants is extremely complex.
Gestational age, caloric needs, immaturity of the gastrointestinal tract, immature suck, swallow,
breathe pattern, and lack of oral feedings play a role in the initiation of enteral feedings (Gregory
& Connolly, 2012). However, ideal enteral feeding guidelines for preterm infants have not been
well defined. There are varying opinions on 1) when to start feedings, 2) feeding volumes in
preterm infants, 3) methods of advancement of feedings, and 4) need for gastric residual
measurements (Caple et al., 2004).
GASTRIC RESIDUALS IN THE PRETERM INFANT
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The Premature GI System
Extremely preterm infants born less than 28 weeks gestation are at greatest risk for
feeding intolerance and developing NEC due to their immature gastrointestinal system
(Ganapathy, Hay, & Kim, 2012; Neu, 2007). Immature and unorganized gastric motility is
related to their immature enteric nervous system. The immature response causes a delay in
transit, leading to bacterial overgrowth and distention secondary to fermentation and gas build
up. This poor motility also creates the environment that leads to initiation of the inflammatory
cascade and can lead to the development of necrotizing enterocolitis (NEC) (Neu, 2007).
Necrotizing Enterocolitis.
NEC carries a 20% to 50% mortality rate with morbidities including strictures, adhesions,
and short bowel syndrome (Neu, 2007). NEC is one of the most feared diseases within the
NICU (Neu, 2007). It is estimated that of those infants weighing less than 1,250 grams, 6-7%
will develop NEC (Ganapathy, Hay, & Kim, 2012). While it has many causes, it been most
associated with enteral feedings, lack of breastfeeding, ischemia, and infections (Cobb, Carlo, &
Ambalavanan, 2004). With 90% of cases seen in preterm infants, prematurity is a primary risk
factor, and one factor causing many physicians to withhold enteral feedings for a prolonged
period of time (Neu, 2007). Although the relationship is unknown, feeding intolerance is very
common among preterm infants and considered to be a precursor to NEC (Moore & Wilson,
2011).
Feeding Intolerance
Feeding intolerance in the preterm infant is extremely common and can cause many
obstacles for infants in the NICU. According to Cobb, Carlos, & Ambalavanan (2004), feeding
intolerance is characterized by gastric residuals obtained prior to feedings, emesis, or abdominal
GASTRIC RESIDUALS IN THE PRETERM INFANT
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distention. However, there are currently no set standards for the management of gastric residual
volumes obtained from aspiration of stomach contents prior to each feeding. In addition, a
unanimous definition of feeding intolerance is lacking despite its repeated use in the literature
(Moore & Wilson, 2011). The assessment of gastric residuals prior to feedings is a common
practice in the NICU for determining feeding tolerance. However, the acceptable amount of
residual and color varies among providers. The management of the gastric residual can be to refeed the semi-digested stomach contents, discard the residual, or re-feed and subtract the volume
from the next feeding (thereby decreasing the total fluid intake).
Cost
Determining the daily cost of a NICU stay is difficult. Many factors influence costs
including the neonatologist, specialty consults, procedures, nursing, medications, and laboratory
studies. However, March of Dimes (2011) published a document addressing this issue. Of
180,000 infants born, 14.4 % required a NICU admission with 49% of these admissions being
preterm infants. Infants born less than 32 weeks had an average hospital stay of 46.2 days and an
average hospital charge of $280,811. This is nine times more than infants born at 39-41 weeks
gestation who averaged $29,771 and 4.9 hospital days. Another study completed at the
University of Chicago concluded that a total of 1,660 ventilated infants who occupied 95,360
days in the hospital, averaged a hospital bill of $114,000. Of these infants, 583 were extremely
low birth weight (ELBW) weighing less than 1,000 grams. Specifically these infants occupied a
NICU bed 50,661 hospital days and averaged $226,000 per infant for their stay (Meadow et al.,
2011).
Ganapathy, Hay, & Kim (2012) address costs specific with the development of NEC.
These authors state that of the 2,560 extremely preterm infants, 259, or 10%, developed medical
GASTRIC RESIDUALS IN THE PRETERM INFANT
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NEC, with 82, or 3.2%, requiring surgery. In this study, more co-morbidities also existed in the
NEC group and included: respiratory distress, infection, and hemorrhage. The average length of
stay for the extreme preterm infant was 64.5 days with an average cost of $207,378. Those
infants who developed medical NEC averaged an additional 11.7 days and $74,004, while those
who required surgical intervention averaged an additional 43.1 days and $198,000. This study
demonstrated the significant impact of developing NEC and the importance of its prevention.
Significance
Currently, there is no standard that addresses the appropriate or acceptable amounts of
gastric residuals, and no clear definition of feeding intolerance in the preterm population. This
indicates a significant gap in the literature. Feeding intolerance among the preterm population is
a common occurrence in the NICU and has been shown to have a direct correlation to the
development of NEC (Moore & Wilson, 2011). With the continued increase in preterm births,
one of Healthy People 2020 goals is to reduce the mortality rate associated with infants born
after 20 weeks gestation from 6.2:1,000 live births in 2005 to 5.6:1,000 live births in 2020
(2014). NEC is listed as one of the leading causes of infant death having a high mortality rate
among very low birth weight (VLBW) infants (Heron, 2013). Therefore, determining the
presence or absence of any correlation between gastric residuals, feeding intolerance, and NEC is
of clinical significance.
Much of the research conducted has focused on reducing the occurrence and improving
symptoms of feeding intolerance to provide physicians with a plan of care to distinguish an
immature gastrointestinal tract in the preterm infant from the initial stage of NEC (Moore &
Wilson, 2011). However, VLBW infants can be very challenging when it comes to advancement
of enteral feedings. Signs of feeding intolerance are common, causing a disruption in enteral
GASTRIC RESIDUALS IN THE PRETERM INFANT
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feedings. These disruptions cause delays in feeding advancement, a delay in reaching the
infant’s targeted growth, and increased hospital length of stays (Carter, 2012).
Feeding intolerance is one of the most significant factors contributing to growth failure in
VLBW infants. Due to the immature gastrointestinal system in preterm infants, establishing and
tolerating enteral nutrition is difficult. To ensure adequate growth and long term cognitive and
neurologic development, enteral nutrition is important. Nutritional goals (120 ml/kg/day) are
directed at replacing the initial weight loss, which can be as much as twenty percent, and to
mimic intrauterine growth (Carter, 2012). However, without a universal definition, developing
appropriate guidelines is difficult.
Clinical Problem Statement
Gastric residuals in the neonatal intensive care unit are a common finding, with many
providers associating it with feeding intolerance despite a lack of evidence. This association
causes unnecessary delays in feeding advancement, weight gain, and growth, which can have
long-term effects on infants (Carter, 2012). More research is needed to determine the role of
gastric residuals in preterm infants and how they relate to feeding intolerance and feeding
advancement. Minimizing adverse effects while optimizing nutrition in neonates requires
evidence-based standards of care.
Purpose
Utilizing research of current evidenced-based literature and a prospective study, the
purpose of this project was to explore providers’ response to gastric residuals and identify any
possible association to feeding intolerance and delays in achieving full feedings, among
premature infants in the neonatal intensive care unit. The anticipated outcome was that
withholding feedings based on gastric residuals would negatively affect feeding advancement.
GASTRIC RESIDUALS IN THE PRETERM INFANT
Aim 1: To identify the frequency of feedings being held due to gastric residuals and the
relationship to feeding intolerance.
Aim 2: Describe the differences in providers’ response to gastric residual volumes.
Literature Review
A search was conducted for information pertaining to the delays that feeding intolerance
and gastric residuals have in achieving full feedings in preterm infants.
Defining Factors
The literature most often describes feeding intolerance by gastric residuals, emesis
abdominal distention, and bloody stools (Carter, 2012, Fanaro, 2012). Bombell & McGuire
(2009) concluded in their Cochran review that feeding intolerance was related to the number of
days required for an infant to reach full enteral feedings without requiring parenteral
supplementation. Barney, Purser, and Christensen (2006) defined feeding intolerance as a
disruption three days in a row of an infant’s individualized feeding plan. Other factors that play
a role are positioning, gestational age, formula vs. breast milk, and certain medications (Carter,
2012). Finally, Moore & Wilson (2011) developed a concept analysis of feeding intolerance
because of the serious implications it can have, yet no standardized guidelines are in place. In
their literature review of more than one hundred articles, the most common complications noted
were gastric residuals, abdominal distention, and emesis.
Residuals and Abdominal Distention
Gastric residual volumes are a reflection of the immature gastrointestinal tract with
delayed gastric emptying, decreased motility, and gastric reflux (Fanaro, 2013). Gregory and
Connolly (2012) found that gastric residuals were the most common reason to delay or change
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enteral feedings. The volume and color of gastric residuals associated with feeding intolerance
varies among hospitals, and within the literature.
The majority of researchers agreed that the most significant gastric residual volume was
50% of the previous feeding. Ng and Shah (2008) described feeding intolerance in a Cochrane
review of gastric residuals as “more than 50% of previous feed, or more than 30% of previous
feed on more than one occasion, or more than 10% of daily feed volume” (p. 3). In addition,
Moore and Wilson (2011) concluded, in their concept analysis, that the most commonly used
clinical value was 50% of the previous feeding when determining FI. However, Mihatsch et al.
(2002) determined a gastric residual in very low birth weight infants during the first 14 days of
feeding advancement was up to 2 ml for infants less than 750 grams and up to 3 ml for those
infants greater than 750 grams. If the residual was more than those amounts, the feeding was
held or the residual was subtracted.
The role of color in gastric residuals was also inconsistent. While some studies included
all green or bile-stained residuals with feeding intolerance, other studies do not. A study of 99
infants determined the color of gastric aspirates was not an indication of FI in preterm infants
averaging 26 weeks gestation (Mihatsch et al, 2002). Carter (2012) stated that bilious or green
residuals are clinically significant, regardless of the amount and was a more “agreed upon”
reason to interrupt feedings. Although it is common practice in the NICU to check gastric
residuals, there is a significant lack of evidence to support the safety and necessity of that
procedure (Moore & Wilson, 2011).
Abdominal distention, including increased abdominal girth and dilated bowel loops were
also associated with feeding intolerance in the literature. Carter (2012) discussed the multitude
of other causes for abdominal distention, which included mechanical ventilation and continuous
GASTRIC RESIDUALS IN THE PRETERM INFANT
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positive airway pressure (CPAP). Both of these increased the amount of air traveling down the
esophagus into the stomach leading to a lack of stooling from decreased intestinal motility. An
increase in abdominal girth of two cm or more between feedings is considered enough to warrant
further investigation and an interruption of feedings (Lucchini et al, 2011, Carter, 2012).
Effects on Growth
Extrauterine growth restriction (EUGR) is a primary complication of VLBW infants due
to a combination of factors. Inadequate early nutrition has been shown to have adverse longterm developmental outcomes related to a decrease in the number of brains cells (Su, 2013). The
lack of standardized feeding guidelines, increased residual volumes, or signs of feeding
intolerance can cause providers to prematurely interrupt feedings. Withholding feedings or
subtracting a certain volumes from a feeding can limit the necessary nutrition and calories an
infant requires for growth and can prolong the time till full feedings are reached. Intestinal
motor dysfunction is one of the most critical problems resulting in feeding intolerance in lowbirth-weight infants. Oral coordination and oral feedings are not typically achieved until
approximately 34 weeks gestation. These problems can delay the transition to full enteral
feedings (Neu, 2007).
Theoretical Framework
The AACN Synergy Model was established to support patient’s and family’s needs
through the skills or competencies of the nursing staff. The model consists of eight
competencies of nursing practice and eight patient characteristics. The eight identified nurse
competencies are clinical judgment, caring practices, advocacy/moral agency, response to
diversity, clinical inquiry, facilitator of learning, collaboration, and systems learning (Hardin,
2009).
GASTRIC RESIDUALS IN THE PRETERM INFANT
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The identified nurse competencies are vital while caring for the acute and critically ill.
These characteristics are especially important working in the NICU with patients who are unable
to communicate verbally. The nurse must rely on assessment and critical thinking skills, while
keeping family involved. Clinical judgment consists of the critical thinking and nursing skills
gained through experience and used when caring for a patient. Advocacy is looking out for the
patient and their needs when they are unable to do so, and resolving ethical dilemmas that may
arise. Caring practices utilize behaviors such as compassion, vigilance, engagement, and
responsiveness, which are individualized to each patient and family the nurse cares for.
Collaboration requires teamwork to achieve optimal outcomes and promote the needs of patients
and their families. Systems thinking involves the global understanding of how each decision
impacts that person as a whole. Response to diversity identifies the need for individualized care,
and accounting for their beliefs, ethnicity, family makeup, lifestyle, and alternative therapies.
Clinical inquiry is an ongoing process and involves continued education to stay competent in
current practices through research and education. As the nurse progresses from novice to expert,
the role of the nurse evolves to better meet the needs of the patient and their family. Finally,
facilitator of learning involves the nurse assisting with education to the patient and their families
to allow them to make informed decisions while taking into account adaptations that may be
necessary due to various education levels (Harding, 2009).
Patients are evaluated on eight characteristics which include resiliency, vulnerability,
stability, complexity, resource availability, participation in care, participation in decision
making, and predictability. Although not specifically designed for the NICU setting, the AACN
Synergy Model’s eight patient characteristics are routinely seen and require an assessment by the
nurse. Resiliency, vulnerability, and stability are three more common characteristics applicable
GASTRIC RESIDUALS IN THE PRETERM INFANT
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in the NICU setting. Many of the infants in the NICU would be considered minimally resilient
in that they do not have any of their own reserves, and many have a limited ability to initiate
their own responses. NICU patients are considered vulnerable and fragile, due to their high
susceptibility to illness and dependence on technology or medications. NICU patients can also
be classified based on their stability. Minimally stable infants would require frequent
medications or ventilator changes, while moderately stable infants can tolerate less intervention
or less frequent assessments. They are demonstrating some responsiveness to therapy and can
maintain a “steady state” for a period of time (Swickard, Swickard, Reimer, Lindell, &
Winkelman, 2014).
The AACN Synergy Model has great application within the neonatal intensive care
setting. Caring for infants requires coordination, communication with family, and development
of assessment skills. The long-term outcome is dependent on the parent’s ability to care for and
provide the environment needed for the infants to thrive. Nurses, medical staff, and ancillary
personnel share the same common goal of assisting each infant to achieve an ideal level of
wellness. The nurses bring their background and expertise, and apply it in every situation to
optimize outcomes. Becker, Kaplow, Muenzen, and Hartigan (2006) discussed the use of acute
and critical care nurse practitioners and their application of the Synergy model. With the
neonatal intensive care included, it was found that they have the largest focus with clinical
judgment. They are making decisions based on expertise and evidence-based practices, while
taking into account the whole person. Clinical experiences, knowledge, critical thinking, and
assessment skills are key to providing the best care for the patient.
GASTRIC RESIDUALS IN THE PRETERM INFANT
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Methods
This prospective, exploratory, pilot study was completed at two Midwest NICUs over a
period of two months. A Feeding Data Collection Form (see Appendix A) was distributed to the
infant’s bedside and filled out by the bedside nurse. The infant’s birth weight, amount of
feedings received, amount of gastric residual volume obtained prior to feedings, signs of
abdominal distension, emesis, or intolerance noted, and how the residual was handled (refed,
discarded, or NPO) were recorded. Due to the varying practices at each facility, a specific
feeding protocol was not used outside current practices. The study explored signs of feeding
intolerance and described any relationships between the amount of gastric residual volume and
feeding intolerance. In addition the nursing staff described the providers’ responses to specific
gastric residuals volumes. A descriptive analysis was done on signs of feeding intolerance and
gastric residual volumes.
Setting and Subjects
Infants born at or transported to the Sanford Health Fargo Region NICU and Essentia
Health Fargo Region NICU were recruited for enrollment. Infants with a birth weight of 1800
grams or less regardless of gestational age were enrolled. Due to the exploratory nature of the
study, the ethical considerations are minimal as there will be no intervention group. Infants with
congenital malformations will be excluded from the study.
Results
Data was collected on 17 infants with a total of 1059 feedings recorded. The number of
days infants were observed varied from 2 to 47. Residuals were not present in 56% of the
feedings recorded. Of the 469 decisions that were made on residuals 70% were refed the
residual and given an additional full feeding, 20% of residuals were refed and subtracted from
GASTRIC RESIDUALS IN THE PRETERM INFANT
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the subsequent feeding, 6% of residuals were discarded and the infant was fed a full feeding, 3%
of residuals were refed with no additional feeding given, and 1% of residuals were discarded
with a feeding held or the infant was made NPO (See Appendix B).
Discussion
In this descriptive study, 30% of the feedings resulted in a decrease in fluid volume and
nutritional calories. Infants receive less fluid volumes and nutrition when gastric residuals are
measured. There is a lack of consensus regarding using gastric residuals as an indicator to
administer subsequent feedings. Torrazza, et al. (2015) found infants without routine gastric
residual evaluation reached full feedings sooner and had fewer days of venous access than those
who do not have routine gastric residual evaluation. The absence of routine gastric residual
measurement was not found to be associated with any negative outcomes such as NEC. There
are some units where measuring gastric residuals are not done. In units without routine gastric
residual evaluation, the infants can reach full feedings sooner, have their peripheral or venous
lines removed sooner, have less pain from intravenous access attempts, and possibly be
discharged from the NICU sooner (with less hospital days).
There was no relationship seen between those infants with signs of feeding intolerance
and those infants with NEC. Of those infants in the study, one infant developed NEC after the
study was completed. This infant did not have increased gastric residual volumes. Therefore,
the measurement of gastric residual volumes may not be necessary and this needs to be explored
further.
Limitations
The small sample size and variations in the feeding protocols between the two
participating NICUs limited the strength of the study. The different practices in feeding
GASTRIC RESIDUALS IN THE PRETERM INFANT
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advancement and continuous versus bolus feedings also presented a challenge in combining the
results.
Conclusions
The routine use of gastric residuals to assess feeding tolerance is common practice in the
NICU. Providers continue to make decisions based on gastric residuals that are not evidencebased. The data collected illustrated the vast variety of ways providers manage gastric residual
volumes. The decisions are not based on scientific evidence. Residuals were refed, discarded, or
subtracted even when there were no other symptoms of feeding intolerance. This information
supports the need for further research regarding gastric residuals and how to best manage the
information we obtain when checking a residual.
GASTRIC RESIDUALS IN THE PRETERM INFANT
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APPENDIX A
DOB
GA
BW
DOL
CGA
Today’s Date______________
Infant’s Assigned Data Collection Number ___________
Instructions: Please fill out daily. If the gastric aspirate requires provider notification, provide the
order received and any feeding intolerance symptoms. Thank you!
Feeding
Fdg
Gastric
#
Volume
Aspirate
1
2
3
4
5
6
7
8
9
10
11
12
Action
Comments
GASTRIC RESIDUALS IN THE PRETERM INFANT
21
APPENDIX B
Gastric Residuals- Provider Response
3%
1%
6%
20 %
70 %
Fed back + Full Feeding
Fed back, subtracted from full feeding
Discarded + Full Feeding
Refed + no additional feeding
Held feeding/NPO