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Running head: GASTRIC RESIDUALS IN THE PRETERM INFANT Gastric Residuals in the Preterm Infant Stephanie Nelson, Rachael Niemeyer, Michelle Omdahl, & Lauren Line Creighton University 1 GASTRIC RESIDUALS IN THE PRETERM INFANT 2 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 3 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 4 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 5 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 6 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 7 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 8 GASTRIC RESIDUALS IN THE PRETERM INFANT 9 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 10 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 11 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 12 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 13 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 14 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 15 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 16 References Arzuaga, B. J., & Meadow, W. (2014). National variability in neonatal resuscitation practices at the limit of viability. American Journal of Perinatology, 31(6), 521-528. http://dx.doi.org/10.1055/s-0033-1354566 Barney, C. K., Purser, N., & Christensen, R. D. (2006). A phase 1 trail testing and enteral solution patterned after human amniotic fluid to treat feeding intolerance. Advances in Neonatal Care, 6(2), 89-95. http://dx.doi.org/10.1016/j.adnc.2006.01.004 Becker, D., Kaplow, R., Muenzen, P. M., & Hartigan, C. (2006). Activities performed by acute and critical care advanced practice nurses: American association of critical-care nurses study of practice. American Journal of Critical Care, 15(2), 130-148. Retrieved from http://ajcc.aacnjournals.org/content/15/2/130.full.pdf+html Bombell, S., & McGuire, W. (2009). Early trophic feeding for very low birth weight infants. Cochran Database of Systematic Reviews, 3. http://dx.doi.org/10.1002/14651858.CD000504.pub3 Caple, J., Armentrout, D., Huseby, V., Halbardier, B., Garcia, J., Sparks, J. W., & Moya, F. R. (2004). Randomized, controlled trial of slow versus rapid feeding volume advancement in preterm infants. Pediatrics, 114(6), 1597-1600. http://dx.doi.org/doi:10.1542/peds.2004-1232 Carter, B. M. (2012). Feeding intolerance in preterm infants and standard of care guidelines for nursing assessments. Newborn and Infant Nursing Reviews, 12(4), 187-201. http://dx.doi.org/10.1053/j.nainr.2012.09.007 GASTRIC RESIDUALS IN THE PRETERM INFANT 17 Cobb, B. A., Carlo, W. A., & Ambalavanan, N. (2004). Gastric residuals and their relationship to necrotizing enterocolitis in very low birth weight infants. Pediatrics, 113(1), 50-53. http://dx.doi.org/10.1542/peds.113.1.50 Fanaro, S. (2012). Strategies to improve feeding tolerance in preterm infants. The Journal of Maternal-Fetal and Neonatal Medicine, 25(54), 54-56. http://dx.doi.org/10.3109/14767058.2012.715021 Fanaro, S. (2013). Feeding intolerance in the preterm infant. Early Human Development, 89, S13-S20. http://dx.doi.org/10.1016/j.earlhumdev.2013.07.013 Ganapathy, V., Hay, J. W., & Kim, J. H. (2012). Costs of necrotizing enterocolitis and costeffectiveness of exclusively human milk-based products in feeding extremely premature infants. Breastfeeding Medicine, 7(1), 29-37. http://dx.doi.org/10.10089/bfm.2011.0002 Goldenberg, R. L., Culhane, J. F., Iams, J. D., & Romero, R. (2009). Preterm birth 1: Epidemiology and causes of preterm birth. Obstetric Anesthesia Digest, 29(1), 6-7. http://dx.doi.org/10.1097/01.aoa.0000344666.82463.8d Gregory, K. E., & Connolly, T. C. (2012). Enteral feeding practices in the NICU: Results from a 2009 neonatal enteral feeding survey. Advances in Neonatal Care, 12(1), 46-55. http://dx.doi.org/doi:10.1097/ANC.0b013e3182425aab Hardin, S. R. (2009). The AACN Synergy Model. In Middle Range Theories: Application to Nursing Research (3rd ed. (pp. 294-305). Phildephia, PA: Lippincott Williams & Wilkins. Heron, M. (2013). Deaths: Leading causes for 2010. National Vital Statistics Report, 62(6), 1-96. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24364902 GASTRIC RESIDUALS IN THE PRETERM INFANT 18 March of Dimes. (2011). Special care nursery admissions. Retrieved from https://www.marchofdimes.com/peristats/pdfdocs/nicu_summary_final.pdf Meadow, W., Cohen-Cutler, S., Spelke, B., Kim, A., Plesac, M., Weis, K., & Lagatta, J. (2011). The prediction and cost of futility in the NICU. Acta Paediatrica, 101(1), 397-402. http://dx.doi.org/10.1111/j.1651-2227.2011.02555.x Mihatsch, W. A., Von Schoenaich, P., Fahnenstich, H., Dehne, N., Ebbecke, H., Plath, C., ... Pohlandt, F. (2002). The significance of gastric residuals in the early enteral feeding advancement of extremely low birth weight infants. Pediatrics, 109(3), 457-459. http://dx.doi.org/ Moore, T. A., & Wilson, M. E. (2011). Feeding intolerance: A concept analysis. Advances in Neonatal Care, 11(3), 149-154. http://dx.doi.org/DOI: 10.1097/ANC.0b013e31821ba28e Neu, J. (2007, February). Gastrointestinal development and meeting the nutritional needs of premature infants. The American Journal of Clinical Nutrition, 85(2), 629S-634S. Retrieved from http://ajcn.nutrition.org/content/85/2/629S.long Ng, E., & Shah, V. S. (2008, July). Erythromycin for the prevention and treatment of feeding intolerance in preterm infants. Cochrane Database of Systematic Reviews, 3. http://dx.doi.org/10.1002/14651858.CD001815.pub2. Su, B. (2013, June). Optimizing nutrition in preterm infants. Pediatrics and Neonatology, 55, 513. http://dx.doi.org/10.1016/j.pedneo.2013.07.003 Swickard, S., Swickard, W., Reimer, A., Lindell, D., & Winkelman, C. (2014, February). Adaptation of the AACN synergy model for patient care to critical care transport. Critical Care Nurse, 34(1), 16-28. http://dx.doi.org/10.4037/ccn2014573 GASTRIC RESIDUALS IN THE PRETERM INFANT 19 Torrazza, R.M., Parker, L., Li, Y., Talaga, E., Shuster, J., & Neu, J (2015). The value of routine evaluation of gastric residuals in very low birth weight infants. Journal of Perinatology, 35, 57-60 doi:10.1038/jp.2014.147. U.S. Department of Health and Human Services. Healthy People 2020. (2014). Maternal, infant, and child health. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=26 GASTRIC RESIDUALS IN THE PRETERM INFANT 20 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