Effect of Non-aspirated Gastric Residual Content on Preterm Infants' Health Status

doi:10.21203/rs.3.rs-1505197/v1

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Effect of Non-aspirated Gastric Residual Content on Preterm Infants' Health Status

https://doi.org/10.21203/rs.3.rs-1505197/v1

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Purpose: The current study aimed to evaluate the effect of non-gastric residual aspiration on preterm infant health status

Methods: The study utilized a quasi-experimental (control and intervention) design. Sixty premature infants were cared for at El Manial University Hospital and Elmonira Pediatric Hospital NICUS. Four tools were utilized: (I) Neonatal personal data; (II) gastric residual observational checklist; (III) the Fenton Growth Weight Chart; and (IV) Modified Bell's Staging Criteria for Necrotizing Enterocolitis

Results: The mean gastric amount in the intervention group was 1.45 ± 0.35, while the control group was 2.53 ± 0.49, with a p-value <0.05. The mean days to full enteral intake of 120 ml kg per day of the intervention group was 7.21±0.66, while the control group was 9.72±0.85, with a slightly significant difference at p-value <0.05. The minority of the intervention group suffered from sepsis, while about one-quarter at the control group. According to NEC, the minority of the intervention group suffered definite.

Conclusion: Eliminating routine prefeed gastric aspirate monitoring decreases late-onset sepsis, permits preterm infants to receive complete enteral feeds sooner, and allows them to leave the hospital sooner. It also did not affect the likelihood of mortality or NEC.

Preterm Infants

Modified Bell's Staging

Necrotizing Enterocolitis

and Gastric Residual

In recent years, preterm births have become one of the most pressing public health issues, and the number of premature babies is steadily rising. A mouth tube or nasogastric intubation feeding is required for premature babies whose swallowing, sucking, and breathing coordination has been compromised. For physiological reasons, bolus gavage feeding is more common in neonatal intensive care units than tube feeding [1]. Providing adequate nutrition is a critical component of the healthcare of preterm infants. There is increasing emphasis on early initiation and appropriate enteral feeds to achieve full-volume enteral feeds at the earliest [2]. Feed intolerance and the risk of necrotizing enterocolitis (NEC), both of which can be deadly, are the two principal obstacles to increasing feed volumes in preterm infants [3].

A key goal of care for LBW infants is to promote weight gain and avoid problems that may have a negative impact on healthy infants' future growth and development. Early enteral feeding is thus advocated in neonatal care and has proved to have benefits such as lower mortality rates, fewer septic problems, faster weight growth, and shorter hospital stays [4]. LBW and preterm newborns suck ineffectively, have poor sucking, swallowing, and breathing coordination, and have delayed stomach emptying. As a result, gavage (tube feeding) is the recommended strategy for providing appropriate nutrition in the early postnatal period [5].

Significance of the study:

Nursing assessments remain an essential technique for detecting early signs of feeding intolerance and preventing it from escalating to a more severe level. The initial expression of feeding intolerance symptoms might be exceedingly modest, necessitating the nurse's close notice of even the tiniest changes in the physical or behavioural status of the preterm newborn. Careful assessment, documenting, and reporting all symptoms from shift to shift can give providers precise data to base intervention decisions. Although providers may differ in terms of when and how to act, nurses should be watchful and report feeding intolerance symptoms as soon as possible [6].

A quasi-experimental (control and intervention groups) research design was utilized in the current study. Sixty preterm neonates at El Manial University Hospital and Elmonira Pediatric Hospital NICUS. Four tools were used: (I) Tool: Neonatal personal data was created by the researcher. It includes characteristics of the preterm infants such as gender, gestational age, age at the start of the study, weight, head circumference and length, date of admission, diagnosis, laboratory investigations, such as C-Reactive Protein (CRP), complete blood count (CBC) with differential, etc…

The researcher created a gastric residual observational checklist, which include the following items: It contains characteristics of gastric residual such as amount and color, mode of Ryle insertion (nasogastric or orogastric), type of feeding, type of milk, amount of feeding, feeding tube size, and time to reach full enteral feeding. The Fenton Growth Weight Chart is a tool (III). Tool (IV) Modified Bell's Staging Criteria for Necrotizing Enterocolitis: Developed by Bell (1978), it is standardized valid, and its reliability is 0.96%. It was first used for measuring NEC levels for preterm infants in 1973, the first attempt to categorize NEC by presentation and severity.

Content validity and reliability

Content validity of the study tool (I) and tool (II) was done by a panel of five expert professors in the field of high-risk neonates and pediatric nursing. Tool (III) WHO Growth Weight Chart is valid, and its reliability is 0.98%. Tool (IV), Modified Bell's Staging Criteria for Necrotizing Enterocolitis standardized by Bell (1978), is valid, and its reliability is 0.96%. The Alpha-Coefficient test was used to check the reliability of tools (I) and (II).

Procedure

The researcher explained the study's purpose and nature to each child's parents who met the inclusion criteria after obtaining permission from the Pediatric El Monira and El Manial University Hospital Directors. Then, one of the parents of the neonates who met the requirements gave written consent. A control group (G2) was assigned first in the NICUs of Elmonira and El Manial University Hospitals, followed by an intervention (G1). Both NICUs feed preterm newborns the same way. For both groups, the researcher informed the nurses about the study's purpose and how to fill out tool (I): neonatal personal data sheet, tool (II): a gastric residual observational checklist, and tool (III): Fenton growth chart. A pre-exam assessed nurses' prior knowledge of research tools. The nursing staff in both units received three consecutive training sessions. Detailed instructions on using the research tools and applying the nursing techniques were provided. A post-exam was held to check for knowledge and understanding of using processes and filling out research tools when the researcher was not around.

Intervention group (G1): When entering the unit to collect initial data, research tool No. I determine the child's demographic data. This is followed by the NEC's third measurement tool. There are eight feedings per day (6 am, 9 am, 12 pm, 3 pm, 6 pm, 9 pm, 12 am, 3 am), with a 3-hour time difference. The gastric tube was opened rather than the residual stomach being extracted. The residue characteristics are checked half an hour before each feeding operation to empty the stomach of possible residuals. The unit's internal feeding is based on the findings of those observations. The third and fourth research tools are then used every day after the third feeding at twelve o'clock in the afternoon for the duration of the child's stay in the unit.

No Intervention (control group) (G2): Tool (1), (II), (III), and (IV) were applied on admission to collect the baseline data by the researcher. The no intervention (control) group received three hourly feeds (6 am, 9 am, 12 pm, 3 pm, 6 pm, 9 pm, 12 am & 3 am), with immediate gastric residuals being aspirated by negative pressure. The researcher checked the residual content characteristics using a tool (II). The number of enteral feeds was based on the NICU's recorded observation and feeding protocol. Tools (III) and (IV) were used daily for each preterm before the third feed.

The current study revealed that less than two-thirds of the intervention group were female, and more than half of the control group were female, with no significant difference >0.05. Related to gestational age, the intervention group's mean was 32.13±3.34, and the control group was 32.68±2.99 with a p-value >0.05. According to chronological age, the intervention group's mean was 75.19 ± 12.89, and the control group was 74.88 ± 11.56, with a slightly significant difference between the two groups at a p-value <0.05. According to the length of stay at a hospital, the intervention group's mean was 8.96 ± 2.56. The control group was 9.11 ± 3.01with a slightly significant difference between the two groups at a p-value <0.05.

Table (1) demonstrated that the mean gastric residual amount of the intervention group on the day of the middle stay at the hospital was 1.45 ± 0.35, while the control group was 2.53 ± 0.49, with a slightly significant difference at p-value <0.05. Related On the last day before discharge, the mean gastric residual amount of the intervention group was 1.03 ± 0.14, while the control group was 1.34 ± 0.19, with a slightly significant difference at p-value <0.05.

Table (2) detected that the minority of the intervention group suffered from suspected A, while the minority of the control group suffered from suspected A, with a slightly significant difference at p-value <0.05. Also, only the minority of the intervention group was mildly ill, while the minority of the control group was mildly ill, with a slightly significant difference at p-value <0.05.

Table (3) demonstrated that the mean days to full enteral intake of 120 ml kg per day of the intervention group was 7.21±0.66, while the control group was 9.72±0.85 with a slightly significant difference at p-value <0.05. Related days of PN, mean of the intervention group was 2.32±0.34, while the control group was 4.12±0.65, with a slightly significant difference at p-value <0.05. Related Days to discharge, mean of the intervention group was 11.96 ± 2.56, while the control group was 15.11 ± 3.01, with a slightly significant difference at p-value <0.05.

Table (4) demonstrated that the minority of the intervention group suffered from sepsis, compared with about one-quarter of the control group. According to NEC, the minority of the intervention group suffered definite NEC, compared to 13.3% of the control group. According to weight at discharge, the mean weight of the intervention group was 2.360± 70.13 kg, while that of the control group was 2.236± 93.40 kg with a p-value <0.05.

Table (5) stated that the high significant model detected through the F test value was 7.990 with a p-value. 001**. This model explained 35% of the variation in days to full enteral intake of 120 ml kg per day detected through R2 value 0.35. Also, it explained that gestational age and chronological age had high-frequency positive effects at p-value <0.01**. At the same time, the Apgar score had a slightly positive impact at p-value <0.05*. Meanwhile, stay at the hospital had a negative effect at p-value <0.05*. But gender and obstetric history had no effect at p-value >0.05*.

Figure (1) demonstrated that the mean gastric residual amount of the intervention group on the day in the middle stay at the hospital was 1.45 ± 0.35, while the control group was 2.53 ± 0.49. Related Last day before discharge, the mean gastric residual amount of the intervention group was 1.03 ± 0.14, while the control group was 1.34 ± 0.19.

Figure (2) demonstrated that the mean growth weight chart of the intervention group on the day of the middle stay at the hospital was 2.194± 90.88, while the control group was 2.115± 96.5. Related On the last day before discharge, the mean growth weight chart of the intervention group was 2.360± 70.13, while the control group was 2.236± 93.40.

Regarding chronological age, the mean age of the intervention study was 75.19 ± 12.89, while the control group was 74.88 ± 11.56, with a slightly significant difference at p-value <0.05*. These results in cohort with the study conducted by [7] titled in the impact of routine evaluation of gastric residual volumes on time to achieve full enteral feeding in preterm infants, revealed that there was a highly significant difference between the study and control group about the time of initiation feeding.

According to stay at a hospital, the current study revealed that the intervention group's mean 8.96 ± 2.56, and the control group was 9.11 ± 3.01with a slightly significant difference between the two groups at a p-value <0.05. This outcome is in disagreement with [8] entitled "Gastric residual volumes versus abdominal girth measurement in the assessment of feed tolerance in preterm neonates" and showed that the gastric residual group had more duration of hospital stay than the control group without a significant difference between the two groups at a p-value >0.05. this difference between studies might be due to the healthcare system that provides global payment for an admission of a preterm infant (<1750 g at birth), regardless of how long or complicated the hospitalization may occur.

In terms of diagnosis, the current study found that the majority of the analyzed sample in both groups had jaundice. This conclusion contrasts with the findings of [9], who conducted a study on "Routine stomach residual volume measurement and energy target accomplishment in the PICU: a comparison study" and found that the majority of the investigated sample in both groups experienced respiratory failure.

Concerning Apgar score, more than three-quarters of the intervention group had scores ranging from 7 to 10. The majority of the control group had scores ranging from 7 to 10 with no significant difference at p-value >0.05, this result consistent with an impact by [10] , who conducted a study about " Association of gastric residual volumes with necrotizing enterocolitis in extremely preterm infants a case-control study" and revealed that (90.0% & 75.0% ) of the study and control groups respectively had more than seven scores with no significant difference at p-value >0.05. Moreover, this finding supported with (Ameri, Rostami, Baniasadi, Aboli, & Ghorbani, 2018), who conducted a study about " The Effect of Prone Position on Gastric Residuals in Preterm Infants" and mentioned that majority of the studied preterm infants had score ranged from 7 to 10 with no significant difference at p-value >0.05.

Regarding the amount of gastric content, table (1) showed that the mean Amount of gastric Amount in the intervention group was 1.45 ± 0.35, while the control group was 2.53 ± 0.49, with a p-value <0.05. this result matched with [2], who conducted a study about " Gastric Volume Changes in Preterm Neonates during Intermittent and Continuous Feeding-GRV and Feeding Mode in Preterm Neonates" and showed that an amount of gastric content in studied preterm infants in the control group had of 4.5 mL as compared to 2 mL in the study group with a p-value <0.05.

Conversely, this outcome is inconsistent with the result by [11], who conducted a study about "The effect of massage on feeding intolerance in premature infants: a systematic review and meta-analysis study" and showed that the mean of the total GRV before and after the intervention in both groups, the results showed that the mean of the total GRV before the intervention between the two groups was not statistically significant (p < 0.05). However, in comparison of the mean of the total GRV after the intervention in the case group (97.30 cc) was less than the GRV was not changed in the case group before and after of intervention, significantly; however, it was increased in the control group (p < 0.001).

Concerning Modified Bell's Staging Criteria for Necrotizing Enterocolitis, Table (2) detected that a minority (3.3%) of the intervention group suffered from suspected A, while less than one-fifth of the control group suffered from suspected A, with a slightly significant difference at p-value <0.05. this result was disliked with [7] entitled " The impact of routine evaluation of gastric residual volumes on time to achieve full enteral feeding in preterm infants" and presented that (1.3% &3.3%) of study and control group suffered from suspected A without a significant difference at p-value >0.05.

In terms of comparing the two groups' outcomes, table (3) showed a clear difference in how many days it took the intervention and control groups to achieve full enteral feeding. The intervention group took less time than the control group. Researchers [12] investigated whether it is necessary to control gastric residuals in premature newborns and found that the answer was yes. There was no significant difference in the number of days of parenteral nutrition between groups one and two, with a p-value of 0.91, when AGRA examined the avoidance of residual gastric aspiration. Even though NEC, weight at discharge, and length of hospitalization were all comparable in the groups that did not have routine residual control (p>0.05), the duration of parenteral nutrition was significantly shorter in the group that did not have routine residual control (p<0.05).

Regarding the study's outcomes, the results in table (4) showed a clear difference between the two groups in terms of exposure to gastrointestinal necrosis, incubator infection, and the weight of the child upon discharge from the hospital. These results cohort with the study [12] about Whether we control gastric residuals unnecessarily in premature newborns? AGRA studied: avoidance of residual gastric aspiration and stated that the group without routine residual control had a shorter time to full enteral intake (p 0.05). Each group's parenteral nutrition duration, grade 2 NEC, weight at discharge, and hospital stay were all comparable. This finding disagreement with [13], who conducted a study about "Routine monitoring of gastric residual for prevention of necrotizing enterocolitis in preterm infants" and illustrated that there a non-significant difference between the study and control group regarding growth weight chart.

Regarding the linear regression model, the current study mentioned that this model explained 35% of the variation in days to full enteral intake of 120 ml kg per day detected through R2 value 0.35. Also, it explained that increased gestational age and chronological age caused shorting time to full enteral intake. In contrast, increase Apgar score shorter time to full enteral intake. Meanwhile, increased stay at hospital cause late at reach to full enteral intake. But gender and obstetric history had no effect at p-value >0.05*. These results are supported by a study by [14] who reported that 37 of 304 admitted infants died before reaching full feeds. Median (interquartile range) gestation, birth weight, and time to full feed (TFF) were 31.4 (30–33.05) weeks, 1210 (1066–1400) g, and 11 (8–15) days, respectively. Gestation and birthweight were inversely correlated with TFF, whereas low Apgar's, sepsis, patent ductus arteriosus (PDA), and respiratory distress syndrome were directly associated with TFF. Growth-restricted infants had significantly shorter TFF vs. appropriate for gestational age infants, probably because of higher gestation.

There is high-quality evidence that discontinuing routine prefeed gastric aspirate monitoring lowers late-onset sepsis, permits preterm infants to accomplish complete enteral feeds sooner, and allows them to leave the hospital sooner. It also did not affect the likelihood of mortality or NEC. In the absence of additional symptoms of feed resistance in preterm low birth weight infants, skipping routine prefeed gastric residue monitoring may be worthwhile.

Author Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Osama Ramadan, Hanan Rashad, Merite Darwish, and Sohier Dabash. The first draft of the manuscript was written by Osama Ramadan and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript \

Competing Interests

The authors have no relevant financial or non-financial interests to disclose.

Ethics approval

Approval was granted by the Ethics Committee of Faculty of nursing, Cairo University B (Date 17/10/20221 /No 2019041701)

Consent to participate

Written informed consent was obtained from the parents.

Acknowledgments

We are thanking all newborns’ family members for accepting in participating in this work, also special thank for prof/ Amira Edris, head of neonatology department for her valuable support and cooperation

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript

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Table 1: Number and percent distribution of studied preterm infants according to their mean gastric residual amount (n=30).

Items	Intervention (n=30)	Control (n=30)	P value
First day of intervention	1.82 ± 0.18	1.91 ± 0.26	0.015*
A day in the middle of the hospital stay	1.45 ± 0.35	2.53 ± 0.49	0.024*
Last day before discharge	1.03 ± 0.14	1.34 ± 0.19	0.027*

Table 2: Number and percent distribution of studied preterm infants according to their Modified Bell's Staging Criteria for Necrotizing Enterocolitis (n=30).

Items

Intervention

(n=30)

Control

(n=30)

P value

Present

Not present

Present

Not present

N (%)

Suspected:

1 (3.3)

0 (0)

29 (96.7)

30 (100)

4 (13.3)

1 (3.3)

26(86.7)

29 (96.7)

0.019*

Definite:

Mildly ill

Moderate ill

1 (3.3)

0 (0)

29 (96.7)

30 (100)

3 (10)

1 (3.3)

27 (90)

29 (96.7)

0.026*

Advanced:

Severely ill, bowel intact

Severely ill, bowel perforated

0 (0)

30 (100)

0 (0)

30 (100)

Table 3: Comparison of the outcome measures between two groups (n=30)

Items	Intervention (n=30)	Control (n=30)	P value
Days to full enteral intake of 120 ml kg per day	7.21.66	9.720.85	0.038*
Days of PN	2.320.34	0.65	0.042*
Days of life parenteral nutrition was discontinued	5.4		0.041*
Days to discharge	11.96 ± 2.56	15.11 ± 3.01	0.045*

Table 4: Comparison of the outcome measures between two groups (n=30)

Items	Intervention N (%)	Control N (%)	P value
Sepsis	4 (13.3)	8 (26.7)	0.031*
NEC (definite).	1(3.3)	4 (13.3)	0.026*
Weight at discharge meanssd	2.360± 70.13	2.236± 93.40	0.018*

Table (5): Multiple Linear regression model for Days to full enteral intake of 120 ml kg per day

			Unstandardized Coefficients B	standardized Coefficients Β	T	P. value
			Unstandardized Coefficients B	standardized Coefficients Β	T	P. value
Gestational age			.299	.189	7.245	.000**
Chronological age			.287	.201	6.098	.002**
Apgar score			.199	.138	3.887	.010*
Gender			.011	.008	1.099	.078
Stay at the hospital			-.244	.167	3,009	.019*
Obstetric history			.013	.009	1.221	.073

Model	R²	Df.		F	P. value
Regression	0.35	6		7.990	.001**

a. Dependent Variable: Days to full enteral intake of 120 ml kg per day

b. Predictors: (constant): Gestational age, Chronological age, Apgar score, Gender, Stay at the hospital and Obstetric history

No competing interests reported.

Download PDF

Journal Publication

published 30 Apr, 2022

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Effect of Non-aspirated Gastric Residual Content on Preterm Infants' Health Status

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