Body Composition of Infants With Congenital Gastroschisis.

ABSTRACT: Infants born with congenital gastroschisis are at risk for intrauterine growth restriction, small for gestational size at birth, and growth failure during the newborn period despite advanced care. Body composition provides a more complete picture of proportional growth than weight and length alone. Fat-free mass (FFM) represents organ growth, and in preterm infants without gastroschisis, improved FFM deposition is associated with improved neurodevelopmental outcomes. There is limited literature regarding the body composition of infants with gastroschisis. This case series describes the body composition of 10 infants with gastroschisis.

Quality Improvement Efforts Reduce Incidence of Surgical Necrotizing Enterocolitis and Related Deaths.

OBJECTIVE: The aim of this study was to determine whether a regional quality improvement (QI) initiative decreased incidence and severity of surgical necrotizing enterocolitis (NEC) in very low birth weight (VLBW) infants. STUDY DESIGN: A retrospective review of all VLBW infants who received care at one of the three hospitals involved in a NEC QI initiative from 2011 to 2016. Primary outcome was the number of surgical NEC cases per year. Secondary outcomes included associated outcomes and mortality. RESULTS: Sixty-three infants with either a diagnosis of Stage III NEC (n = 40) or spontaneous intestinal perforation (SIP) (n = 23) were included. The incidence of medical and surgical NEC and the mortality rate of infants with surgical NEC decreased over time. Incidence and mortality of SIP did not significantly change. CONCLUSION: A regional QI bundle to reduce the overall incidence of NEC also significantly decreased the incidence of surgical NEC and all-cause mortality of infants diagnosed with surgical NEC. KEY POINTS: · QI reduces surgical necrotizing enterocolitis.. · Reduction in NEC rate improves mortality.. · Human milk does not change SIP incidence..

Factors that Influence Longitudinal Growth from Birth to 18 Months of Age in Infants with Gastroschisis.

OBJECTIVE: This study aimed to investigate factors that influence growth in infants with gastroschisis. STUDY DESIGN: Growth parameters at birth, discharge, 6, 12, and 18 months of age were collected from 42 infants with gastroschisis. RESULTS: The mean z-scores for weight, length, and head circumference were below normal at birth and decreased between birth and discharge. Lower gestational age correlated with a worsening change in weight z-score from birth to discharge (rho 0.38, p = 0.01), but not with the change in weight z-score from discharge to 18 months (rho 0.04, p = 0.81). There was no correlation between the day of life when the enteral feeds were started and the change in weight z-score from birth to discharge (rho 0.12, p = 0.44) or discharge to 18 months (rho -0.15, p = 0.41). CONCLUSION: Our study demonstrates that infants with gastroschisis experience a significant decline in weight z-score between birth and discharge, and start to catch up on all growth parameters after discharge. Prematurity in gastroschisis infants is associated with a greater risk for weight loss during this time. This information emphasizes the importance of minimizing weight loss prior to discharge in premature infants with gastroschisis and highlights the need for optimal management strategies for these infants.

Nutrition for the Surgical Infant with Gastroschisis.

Nutrition for the infant with gastroschisis is a complex topic and there is not a lot of uniformity in the literature to formulate evidence-based care. This article discusses more recent findings in the literature as we search for an effective method of feeding these infants. Issues with growth and development, illustrating the variety of outcomes, are also addressed.

Evaluation of Early Onset Sepsis, Complete Blood Count, and Antibiotic Use in Gastroschisis.

OBJECTIVE: Gastroschisis is a congenital defect in which the abdominal viscera herniate through the abdominal wall. In this population, antibiotics are often initiated immediately following delivery; however, this may be unnecessary as infections typically develop as a consequence of chronic issues in gastroschisis. The objective of this study was to evaluate the incidence of culture positive early onset sepsis, the reliability of the immature to mature neutrophil count (I:T) ratio as an infectious biomarker, and antibiotic use in infants with gastroschisis. STUDY DESIGN: This retrospective chart review analyzed clinical data from 103 infants with gastroschisis and 103 weight-matched controls that were evaluated for early onset infection. RESULTS: Compared with the control group, there was a significantly increased percentage of infants with an I:T ratio > 0.2 in the gastroschisis group (43% vs. 12%, p < 0.001) and an increased percentage of infants exposed to greater than 5 days of antibiotics regardless of their I:T ratio (75% vs. 6%, p < 0.001). There were no episodes of culture positive early onset sepsis in either group. CONCLUSION: Our results indicate that I:T ratio is not a reliable marker of infection in gastroschisis, and suggest that empiric septic evaluation and antibiotic use, immediately following delivery in gastroschisis infants, may be unnecessary.

Complementary food introduction practices in infants with intestinal failure.

BACKGROUND: Oral intake in infants with intestinal failure (IF) may be limited due to intolerance or feeding difficulties. Guidelines for the introduction of semisolid or solid complementary foods (CFs) to infants with IF do not exist. CF intake and caloric contribution from CF is difficult to assess due to malabsorption and incomplete recording. The aim of this study was to identify institutional approaches to introducing CF to infants with IF. METHODS: The American Society for Parenteral and Enteral Nutriton (ASPEN) Pediatric Intestinal Failure Section Registered Dietitian/Nutritionist (RDN) working group designed a 10-question online cloud-based survey to assess group member practice related to the introduction of CF to infants with IF. RESULTS: Twenty-six surveys were completed. Thirteen (50%) RDNs recommend introduction of CF between 4 and 6 months of age. Nineteen (76%) recommend adding pureed foods to gastrostomy tube feedings. Seventeen (65%) follow standard infant feeding practice guidelines with half citing the American Academy of Pediatrics. Approximately half (44%) recommend introducing vegetables first and the majority (80%) recommend delaying the introduction of fruits. The vast majority (92%) recommend specific foods to minimize stool output including green beans, bananas, infant cereals, and meats/protein. CONCLUSION: Institutional practices related to the introduction of CF to infants with IF vary. Similarities with first food choice and foods to avoid were observed. Evidenced-based practice guidelines for the introduction of CF to infants with IF need to be established to determine best practices for reducing stool output, encouraging weaning from parenteral nutrition, and achieving enteral autonomy.

Delay in achieving enteral autonomy and growth outcomes in very low birth weight infants with surgical necrotizing enterocolitis.

OBJECTIVE: To understand the nutritional intake and growth outcomes of very low birth weight infants with surgical necrotizing enterocolitis (NEC). STUDY DESIGN: In a retrospective cohort study, linear mixed models were used to compare growth outcomes from birth to 24 months corrected age for very low birth weight (VLBW) infants with surgical NEC to those with spontaneous intestinal perforation (SIP). Kaplan-Meier curves were developed to demonstrate the duration of parenteral nutrition (PN) use. RESULT: Height differed by surgical NEC and SIP over time (interaction p = 0.03). Surviving infants with surgical NEC had lower head circumference z-scores at 24 months. Of infants surviving surgical NEC, 71% received PN for >60 days after diagnosis. CONCLUSION: The majority of infants with surgical NEC have a delay in achieving enteral autonomy. There was a difference in linear catch-up growth over time between infants with SIP and surgical NEC at 24 months.

Feeding Tolerance, Intestinal Motility, and Superior Mesenteric Artery Blood Flow in Infants with Gastroschisis.

OBJECTIVE: The aim of this study was to determine the relationship of superior mesenteric artery (SMA) blood flow and intestinal motility with feeding tolerance in infants with gastroschisis. STUDY DESIGN: This was a prospective observational cohort study of 23 infants with gastroschisis. Magnetic resonance images were obtained at abdominal wall closure, initiation of feeds, and full feeds. Motility and SMA flow data were correlated with feeding tolerance. RESULT: All infants had abnormal motility, and most continued with abnormal motility despite achieving full feeds. Increased SMA flow at the time of abdominal wall closure was found to be significantly related to the earlier achievement of full feeds (ρ = -0.45, p = 0.05) and trended towards earlier initiation of feeds (ρ = -0.36, p = 0.13), shorter parenteral nutrition days (ρ = -0.42, p = 0.07), and earlier discharge (ρ = -0.41, p = 0.08). CONCLUSION: Increased SMA blood flow at the time of abdominal wall closure is positively correlated with feeding tolerance, suggesting the importance of initial intestinal perfusion in the pathophysiology for feeding intolerance and intestinal dysmotility in gastroschisis.

Nutritional management of infants with short bowel syndrome.

The prevalence of short bowel syndrome appears to be increasing because of more aggressive surgical and medical approaches to the management of neonatal intraabdominal catastrophies. Hence, a large cohort of neonates with intestinal failure occupies neonatal intensive care units, requiring chronic total parenteral nutrition (TPN) in hopes that the residual bowel will adapt, thereby permitting weaning of TPN. Alternatively, when there is no hope for adaptation, these infants are maintained on TPN in hopes that they will grow to a size and state of general health satisfactory for either isolated intestinal transplant when liver function is preserved or combined liver-intestinal transplantation when the liver is irreparably damaged. Thus, it is imperative to provide enough parenteral nutrition to facilitate growth while minimizing TPN constituents predisposing to liver damage. Liver disease associated with intestinal failure (IFALD) seems to occur due to a variety of host factors combined with deleterious components of TPN. Host factors include an immature bile secretory mechanism, bile stasis due to fasting, and repeated septic episodes resulting in endotoxemia. Many constituents of TPN are associated with liver damage. Excessive glucose may result in fatty liver and/or hepatic fibrosis, excessive protein may lead to reduced bile flow, and phytosterols present in intravenous lipid may produce direct oxidant damage to the liver or may impede cholesterol synthesis and subsequent bile acid synthesis. Parenteral strategies employed to minimize TPN damage include reducing glucose infusion rates, reducing parenteral protein load, and reducing parenteral lipid load. Furthermore, preliminary studies suggest that fish oil-based lipid solutions may have a salutary effect on IFALD. Ultimately, provision of enteral nutrition is imperative for preventing or reversing IFALD as well as facilitating bowel adaptation. While studies of trophic hormones are ongoing, the most reliable current method to facilitate adaptation is to provide enteral nutrition. Continuous enteral feeding remains the mainstay of enteral nutrition support.

ASPEN Safe Practices for Enteral Nutrition Therapy [Formula: see text].

Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors. The latter can occur at any step from patient assessment, prescribing, and order review, to product selection, labeling, and administration. To maximize the benefits of EN while minimizing adverse events requires that a systematic approach of care be in place. This includes open communication, standardization, and incorporation of best practices into the EN process. This document provides recommendations based on the available evidence and expert consensus for safe practices, across each step of the process, for all those involved in caring for patients receiving EN.

Follow-Up Survey on Functionality of Nutrition Documentation and Ordering Nutrition Therapy in Currently Available Electronic Health Record Systems.

BACKGROUND: This is a follow-up survey to reassess the safety and efficacy of nutrition content in the available electronic health record (EHR) systems. MATERIALS AND METHODS: Members of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), American Society for Nutrition, and the Academy for Nutrition and Dietetics were asked to participate in an online survey. The survey included questions from a 2012 EHR survey on the safety and efficacy in 5 nutrition content areas as well as questions from previous 2003 and 2011 A.S.P.E.N. parenteral nutrition (PN) surveys. RESULTS: Percent of respondents using an EHR and using the EHR for less than 1 year increased between 2012 and 2014 (86%-94%, P < .05; 11%-16%, P < .05, respectively). However, there was no improvement in the safety and efficacy of the 5 nutrition content areas, with a significant decrease in 2 of these areas, ordering oral nutrition supplements and ordering PN. The top-rated EHR vendors had a higher average favorable response rate in regards to safety and efficacy in the nutrition content areas but even the top-rated EHR vendor had only a 60% average in favorable responses. Reported use of electronic PN ordering and a direct interface between the EHR and the automated compounding device (ACD) significantly increased from 2003 to 2011 to 2014 (29% to 33% to 63% and 16% to 19% to 28%, respectively, P < .05). CONCLUSIONS: This is a call to action to nutrition support clinicians, societies, and organizations to proactively be involved in initiatives to educate clinicians and collaborate with EHR vendors to enhance the EHR systems to improve the safety and efficacy of providing nutrition therapy in hospitalized patients.

Safety and Tolerability of Enteral Protein Supplementation for Infants With Brain Injury.

BACKGROUND: We hypothesized that enteral protein supplementation in infants with brain injury would be safe and well tolerated and improve growth. MATERIALS AND METHODS: Twenty-five infants with perinatal brain injury were randomized to a high-protein (4 g/kg/d) or standard-protein diet and followed for 12 months. RESULTS: The whey protein powder was well tolerated by 9 of the 13 infants in the high-protein group, and no adverse events related to the supplement were seen. The protein group had higher serum urea nitrogen at 10 and 30 days after study initiation but no difference in bicarbonate levels at either time point. Infants in the protein group maintained their weight z score from birth to 3 months of age, while infants in the standard group had a significant decrease in their weight z score over the same time period. CONCLUSION: These results suggest that enteral protein supplementation may reduce growth failure in infants with brain injury.