Method of Home Tube Feeding and 2–3-year Neurodevelopmental Outcome

doi:10.21203/rs.3.rs-3617124/v1

Download PDF

Article

Method of Home Tube Feeding and 2–3-year Neurodevelopmental Outcome

https://doi.org/10.21203/rs.3.rs-3617124/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 29 May, 2024

Read the published version in Journal of Perinatology →

You are reading this latest preprint version

Objective: To describe the Bayley Scales of Infant Development 3rd Edition (Bayley-III) of infants discharged home receiving tube feeds

Study Design: Retrospective review of infants discharged with nasogastric or gastrostomy tube feeds and completed a Bayley-III assessment at 2-3-years of age through a neonatal follow-up program. Results were reported using descriptive statistics.

Results: Of infants discharged with nasogastric feeds, median Bayley-III scores were in the low-average to average range and full oral feeds were achieved in 75%. Of infants discharged with gastrostomy tube feeds, median Bayley-III scores were in the extremely low range and full oral feeds were achieved in 36%. Our data set did not demonstrate a distinct patient demographic that correlated to the type of feeding tube at discharge.

Conclusion: Neurodevelopmental outcome at 2–3 years does not appear to be negatively impacted by the decision to discharge an infant from the NICU with home NG feedings.

Health sciences/Health care/Paediatrics

Health sciences/Medical research/Outcomes research

Neonates

neonatal intensive care

enteral nutrition

home feeding tubes

neurodevelopment

One of the critical milestones for infants to meet prior to discharge from the neonatal intensive care unit (NICU) is establishing a safe and manageable feeding plan that promotes healthy growth and development. While some infants tolerate full oral nutrition prior to discharge, others do not due to prematurity, delayed oral feeding skills (1), or other medical conditions affecting oral feeds (2). Those infants who have not yet achieved adequate oral intake are often discharged home with enteral feeding tubes, either nasogastric (NG) tube or gastrostomy tube (GT), to provide supplemental nutrition while they develop their oral feeding skills.

To date, there is no standard of care as to the best discharge feeding practices for infants with delayed oral feeding skills (3). Historically infants with delayed oral feeding were discharged with a surgically placed GT. Previous studies have demonstrated an association between GT use and neurodevelopmental impairment (4, 5). The neurodevelopmental outcomes of infants discharged on home NG feeds are currently unknown. It remains unclear if the delayed oral feeding skills prompting GT placement, prior to NICU discharge, is a potential marker for neurodevelopmental impairment.

A growing body of evidence demonstrates the safety, cost-effectiveness, and practicality of discharge home with NG tubes (6, 7). Recent studies have found fewer tube-related complications requiring emergency department evaluation for infants discharged with an NG tube as compared to a GT (8–10). Several studies report that infants who are discharged home with an NG tube achieve full oral feeds within weeks to months of discharge (7, 8, 11, 12). Conversely, other studies have noted that infants discharged with GT feeds are less likely to achieve full oral feeds by 1 year after discharge.

Our institution supports home enteral feeding through shared decision-making and a standardized algorithm to guide providers in feeding options for discharge (7). Our hypothesis is that with the creation of our standardized algorithm and shared decision-making, our institution would select the most developmentally at-risk infants to receive home GT feedings. To demonstrate this, our aim is to describe the Bayley Scales of Infant Development 3rd Edition (Bayley-III) scores of infants discharged home with NG feeds and their associated feeding outcomes. This study adds to further understanding of the longer-term outcomes of infants discharged home on tube feeds.

After approval from the local Institutional Review Board, a retrospective chart review was performed of neonates who were discharged with NG tube or GT feeds from either a regional level IV referral NICU or surrounding level III NICUs, and who completed follow-up at a regional neonatal follow-up program through a university-associated developmental clinic between October 2016 and June 2022. The discharge feeding method was individualized through a standardized algorithm and shared decision-making model between the feeding team, clinicians, and family (7). The follow-up developmental program sees infants who were born ≤ 26 weeks gestational age, born ≤ 1250 grams, required extracorporeal membrane oxygenation, or have been diagnosed with hypoxic-ischemic encephalopathy. Infants were excluded if they did not have Bayley-III assessment at 2–3 years corrected gestational age, had craniofacial abnormalities precluding safe NG tube placement, or were discharged with transpyloric tube feeds. Collected data included gestational age, birth weight, intraventricular hemorrhage (IVH), respiratory support, discharge feeding method, surgical procedures, and Bayley-III scores at 2–3 years corrected gestational age. Descriptive statistical analysis was used to summarize the data using Prism 9.5.1 software.

During the study period, 90 infants met our inclusion criteria. Of those infants, 65 were discharged with NG feeds, and 25 were discharged with GT feeds. Infant characteristics for both groups are summarized in Table 1.

Table 1

Group characteristics
	NG n = 65	GT n = 25
Female^a	29 (45)	14 (56)
White ^a	46 (71)	19 (76)
Other ^a	19 (29)	6 (24)
Inborn ^a	33 (51)	11 (44)
Singleton ^a	50 (77)	22 (88)
Twin ^a	10 (15)	3 (12)
Triplet ^a	5 (8)	0
Birth weight (g)^b	752 (652, 950)	845 (670, 1070)
ECMO	0	1 (4)
Prematurity
Gestational age (weeks) ^b	25 (24,26)	27 (25, 29)
< 28 weeks ^a	54 (83)	14 (56)
28–32 weeks ^a	4 (6)	5 (20)
32–37 weeks ^a	1 (2)	3 (12)
Term ^a	6 (9)	3 (12)
Neurological Pathology
IVH
-None ^a	30 (46)	16 (64)
-Mild (1–2) ^a	12 (18)	6 (24)
-Severe (3–4) ^a	23 (35)	3 (12)
Encephalopathy ^a	4 (6)	3 (12)
Respiratory Pathology
Nasal Cannula at discharge ^a	54 (83)	14 (56)
Tracheostomy ^a	0	3 (12)
BPD ^a	59 (91)	21 (84)
Abdominal Pathology
Spontaneous Intestinal Perforation ^a	5 (8)	0
Necrotizing Enterocolitis medical ^a	5 (8)	2 (8)
Necrotizing Enterocolitis surgical ^a	6 (9)	1 (4)
^a Number (%) ^b median (Q1,Q3), Nasogastric tube (NG), Gastrostomy tube (GT), Hypoxic Ischemic Encephalopathy (HIE); Extracorporeal Membrane Oxygenation (ECMO); Intraventricular Hemorrhage (IVH); Bronchopulmonary dysplasia (BPD)

Infants discharged with NG feedings

Of the 65 infants discharged with NG feedings, 59 (94%) were preterm, and 23 (35%) had severe (Grade 3–4) IVH (Table 1). Fifty-four (83%) were discharged home with a nasal cannula. At 2–3 year follow-up, 49 (75%) infants had achieved full oral feedings. The median Bayley-III scores were in the low-average range as shown in Table 2 (One child was missing a language score and two children were missing motor scores). Median Bayley-III scores were 90 (IQR 65–100) for cognitive, 89 (IQR 67–99) for language, and 82 (IQR 56–91) for motor. Of the 15 (23%) infants who were discharged on NG feedings and later had a GT placed (mean age of GT placement: 9 months ± 6 months) median Bayley-III cognitive, language, and motor scores were: 60 (IQR 60–70), 59 (IQR 50–71), and 52 (IQR 46–79), respectively (Fig. 1).

Table 2

Outcome at 2–3 years
	Nasogastric (NG) at discharge n = 65	Gastrostomy Tube (GT) at discharge n = 25
Corrected age in months at follow-up	26 (24–28)	25 (24–26)
Feeding method at 2 years of age
Full oral feeding ^a	49 (75)	9 (36)
NG feeding ^a	1 (2)	0
GT feeding ^a	15 (23)	16 (64)
Bayley Scale of Infant Development 3rd edition Scores
Cognitive ^b	90 (65, 100)	70 (55, 85)
Language ^b	89 (67, 99)^†	62 (56, 74)^‡
Motor ^b	82 (56, 91)^‡	64 (52, 79)
^a Number (%), ^b median (Q1,Q3), † missing 1, ‡ missing 2

Infants discharged with GT feedings

Of the 25 infants discharged with a GT, 88% were preterm and 64% did not have IVH, with 12% having a history of severe IVH (Grade 3–4) (Table 1). Fourteen infants (56%) were discharged on a nasal cannula. At 2–3 year follow-up, 10 infants (38%) had achieved full oral feedings, with the remaining infants requiring at least partial GT supplementation. Median Bayley-III scores were low in all categories (Table 2, two infants did not have language scores recorded). Of the 10 infants discharged with a GT who attained full oral feeds by two-three year follow up median Bayley-III cognitive, language, and motor scores were 85 (IQR 70–90), 73 (IQR 56–85), and 76 (IQR 71–88), respectively (Fig. 1).

In this retrospective study, we found a high proportion, 75%, of infants discharged with NG feedings achieved full oral feedings. Their Bayley-III scores were in the average to low-average range (80–109). These scores were similar to the non-tube-fed infants seen in our follow-up clinic. These data suggest that infants discharged on NG feeds have similar neurodevelopmental outcomes to patients without feeding dysfunction at discharge (3).

In contrast, of infants who were discharged with a surgically placed GT, about a third (36%) were able to achieve full oral feeds by follow-up at two years. Infants discharged with a GT also had a more significant developmental delay on follow-up, consistent with other reports of infants discharged with GT feeds (4, 5). Although our numbers are small, those infants who were discharged with GT feeds and achieved full oral feeding by 2–3 years of age Bayley-III testing remained in the low-average to very low range. Infants who require GTs before discharge are more likely to have neurodevelopmental deficits and take longer to achieve oral autonomy.

Prior studies suggested that infants with increased medical complexity including lower gestational age at birth, are more likely to be discharged with GT feeds (3). However, we were unable to identify a distinct patient demographic profile for infants discharged with either NG or GT feeds. In fact, our data demonstrated a greater incidence and severity of IVH in the infants discharged with NG feeds and a low incidence of severe IVH in those infants discharged with GT. This suggests that there are additional factors influencing an infant’s home feeding plan. It’s difficult to assign causality, but these additional factors may be associations of familial socioeconomic status, parental education, access to healthcare resources, perceptions of safe feeding options, and assessment of neurodevelopmental status at the time of discharge. Larger studies on this population could help recognize these differences.

As a retrospective study, there are several intrinsic limitations to this study. The sample size is limited to our geographic region and data recorded in the medical record. Further, there were likely unidentified factors that were not captured in our data set that likely contributed to the choice of feeding method at discharge, such as (but not limited to) post-discharge medical and social support systems. Our patient population may have biased our results as we only included infants who were discharged with a feeding tube (NG or GT) and returned for follow-up at 2–3 years of age for a Bayley-III examination.

There are many considerations to influence discharge feeding plans, explicitly or implicitly, including the patient’s underlying neuromuscular potential, therapist variability, available resources upon discharge including access to follow-up care, family comfort and preferences, and health care team bias. With our limited sample size, our data showed that infants who were discharged with NG and ultimately received a GT had lower Bayley-III scores as compared to those discharged from the NICU with a GT. Since we had very few infants receive a GT after discharge with NG this trend may not be applicable in a larger sample size. Further study is warranted to clarify the optimal home feeding tube method (15).

It has been demonstrated that infants have improved oral intake after discharge and many infants achieve full oral feeds as early as the first week after discharge with NG feeds (3, 7, 11). Earlier discharge with NG feeds may also improve the duration of breastfeeding and exposure to expressed maternal milk (13). It is possible that neurodevelopmental benefits may be gained by prompter discharge home (14). Based on this data there is potential for some infants to be safely discharged to home and reduce their NICU stay duration by utilizing NG feeds temporarily as a bridge to a later surgery date (11, 12), as GT placement is thought to be safer in infants who are older and larger, rather than in the early newborn period.

The next phase of our study should include social determinants of disease data including home zip code, familial education level, access to care, private versus public insurance, and perceptions of providers of safe feeding options, as we did not detect a distinct medical comorbidity profile associated with home feeding tube method.

We found that through our standardized algorithm and shared decision-making did select the most developmentally at-risk infants to receive home GT feedings. However, we were surprised that we were unable to find a distinct patient demographic within the data we had available. Safe and effective feeding methods for this high-risk patient population continue to evolve and continued research is essential to optimizing our feeding, growth, and neurodevelopmental outcomes.

Conflicts of Interest: All authors indicate that they have no financial obligations or conflicts of interest to disclose.

Amaizu N, Shulman R, Schanler R, Lau C. Maturation of oral feeding skills in preterm infants. Acta Paediatrica 2008; 97(1):61.
Shaker CS. Infant-Guided, Co-Regulated Feeding in the Neonatal Intensive Care Unit. Part II: Interventions to Promote Neuroprotection and Safety. Seminars in Speech and Language. 2017;38(2):106–15.
Ermarth A, Ling CY. Partial Enteral Discharge Programs for High-risk Infants. NeoReviews. 2022;23(1):e13–22.
Jadcherla S, Khot T, Moore R, Malkar M, Gulati I, Slaughter J. Feeding Methods at Discharge Predict Long-term Feeding and Neurodevelopmental Outcomes in Preterm Infants Referred for Gastrostomy Evaluation. The Journal of Pediatrics 2017; 181:125–130.
Warren M, Do B, Das A, Smith PB, Adams-Chapman I, Jadcherla S, et al. Gastrostomy Tube Feeding in Extremely Low Birthweight Infants: Frequency, Associated Comorbidities, and Long-term Outcomes. The Journal of Pediatrics. 2019; 214:41.
Vermilyea S, Goh VL. Enteral feedings in children. Nutrition in Clinical Practice. 2016;31(1):59–67.
White BR, Ermarth A, Thomas D, Arguinchona O, Presson AP, Ling CY. Creation of a Standard Model for Tube-feeding at NICU Discharge. JPEN Journal of Parenteral and Enteral Nutrition. 2020; 44(3):491.
Williams SL, Popowics NM, Tadesse DG, Poindexter BB, Merhar SL. Tube feeding outcomes of infants in a Level IV NICU. Journal of Perinatology. 2019; 39(10):1406–10.
Khalil ST, Uhing MR, Duesing L, Visotcky A, Tarima S, Nghiem-Rao TH. Outcomes of Infants with Home Tube Feeding: Comparing Nasogastric Versus Gastrostomy Tubes. JPEN Journal of Parenteral and Enteral Nutrition. 2017; 41(8):1380.
Duncan TL, Ulugia J, Bucher BT. Association of Gastrostomy Placement on Hospital Readmission in Premature Infants. Journal of Perinatology 2019; 39(11):1485.
Ermarth A, Thomas D, Ling CY, Cardullo A, White BR. Effective Tube Weaning and Predictive Clinical Characteristics of NICU Patients With Feeding Dysfunction. Journal of Parenteral and Enteral Nutrition. 2020; 44(5):920–7.
Mago-Shah DD, Malcolm WF, Greenberg RG, Goldstein RF. Discharging Medically Complex Infants with Supplemental Nasogastric Tube Feeds: Impact on Neonatal Intensive Care Unit Length of Stay and Prevention of Gastrostomy Tubes. American Journal of Perinatology. 2021; 38:e207–14.
Meerlo-Habing AE, Kosters-Boes EA, Klip H, Brand PLP. Early discharge with tube feeding at home for preterm infants is associated with longer duration of breast feeding. Archives of Disease in Childhood: Fetal and Neonatal Edition. 2009;94(4):294–7.
Charpak N, Ruiz-Peláez JG, Charpak Y. Rey-Martinez Kangaroo Mother Program: an alternative way of caring for low birth weight infants? One year mortality in a two cohort study. Pediatrics. 1994; 94:804–10.
Collins CT, Makrides M, McPhee AJ. Early discharge with home support of gavage feeding for stable preterm infants who have not established full oral feeds. Cochrane Database Syst Rev. 2015;2015(7)

There is NO conflict of interest to disclose.

Download PDF

Journal Publication

published 29 May, 2024

Read the published version in Journal of Perinatology →

Editorial decision: revise
19 Dec, 2023
Review #2 received at journal
12 Dec, 2023
Review #1 received at journal
06 Dec, 2023
Reviewer #2 agreed at journal
28 Nov, 2023
Reviewer #1 agreed at journal
22 Nov, 2023
Reviewers invited by journal
21 Nov, 2023
Submission checks completed at journal
17 Nov, 2023
Editor assigned by journal
15 Nov, 2023
First submitted to journal
15 Nov, 2023

You are reading this latest preprint version

Method of Home Tube Feeding and 2–3-year Neurodevelopmental Outcome

Status:

Journal Publication

Version 1

Abstract

Figures

Introduction

Subjects and Methods

Results

Infants discharged with NG feedings

Infants discharged with GT feedings

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1