Implementation of standardized feeding pathways for infants with gastroschisis to improve patient outcomes: A quality improvement project in a level IV surgical NICU.

Gastroschisis is a leading cause of pediatric intestinal failure. Feeding guidelines may lead to improved patient outcomes including decreased time to reach full feeds, a reduction in the duration of parenteral nutrition, and reduced length of stay. However, there is limited evidence on what the ideal feeding guidelines are for this complex gastrointestinal diagnosis. In this quality improvement project, after completing a literature review, we created three pathways based on the complexity of the gastroschisis. We reviewed historical data without a defined feeding pathway/guideline to our newly created pathways in the intervention group. The study included 35 patients with varying degrees of gastroschisis complexity, consisting of 9 current patients (October 2021-December 2022) who were provided with defined feeding pathways and 26 historical patients before the protocol was implemented (January 2015-August 2021). There were no significant differences in the number of days required for full feeds between the two groups. However, the mean duration of parenteral nutrition was 18.9 days (95% CI, -31.8 to -7.0) shorter in the intervention group. Although not statistically significant, the patients in the intervention group had a mean length of stay that was 13.1 days (95% CI, -50.0 to 25.4) shorter than the historical group. The creation of standardized feeding guidelines for the gastroschisis population resulted in a statistically nonsignificant decrease in time to reach full enteral feeds, a statistically significant reduced duration of parenteral nutrition, and a statistically nonsignifiant decreased length of stay.

Non-nutritional use of human milk as a therapeutic agent in neonates: Brain, gut, and immunologic targets.

Human milk (HM) exposure improves short- and long-term outcomes for infants due to a complex milieu of bioactive, stem cell, anti-inflammatory, anti-microbial, and nutritive components. Given this remarkable biologic fluid, non-nutritional utilization of HM as a targeted therapeutic is being explored in pre-clinical and clinical studies. This article describes recent research pertinent to non-nutritional uses of HM for neurologic, gastrointestinal, and infectious pathologies in neonates, as well as future directions.

Improving outcomes for uncomplicated gastroschisis: clinical practice guidelines from the American Pediatric Surgical Association Outcomes and Evidence-based Practice Committee.

BACKGROUND: The authors sought better outcomes for uncomplicated gastroschisis through development of clinical practice guidelines. METHODS: The authors and the American Pediatric Surgical Association Outcomes and Evidenced-based Practice Committee used an iterative process and chose two questions to develop clinical practice guidelines regarding (1) standardized nutrition protocols and (2) postnatal management strategies. An English language search of PubMed, MEDLINE, OVID, SCOPUS, and the Cochrane Library Database identified literature published between January 1, 1970, and December 31, 2019, with snowballing to 2022. The Appraisal of Guideline, Research and Evaluation reporting checklist was followed. RESULTS: Thirty-three studies were included with a Level of Evidence that ranged from 2 to 5 and recommendation Grades B-D. Nine evaluated standardized nutrition protocols and 24 examined postnatal management strategies. The adherence to gastroschisis-specific nutrition protocols promotes intestinal feeding and reduces TPN administration. The implementation of a standardized postnatal clinical management protocol is often significantly associated with shorter hospital stays, less mechanical ventilation use, and fewer infections. CONCLUSIONS: There is a lack of comparative studies to guide practice changes that improve uncomplicated gastroschisis outcomes. The implementation of gastroschisis-specific feeding and clinical care protocols is recommended. Feeding protocols often significantly reduce TPN administration, although the length of hospital stay may not consistently decrease.

Improving care and survival of newborns with surgical conditions in Tanzania (TINY Tanzania): a focus on gastroschisis.

PURPOSE: Gastroschisis is associated with over 90% mortality in many sub-Saharan African countries. The introduction of the Gastroschisis Care Bundle at Muhimbili National Hospital (MNH) increased survival up to 60%. We aim to explain the impact of using implementation science methods to decentralize the care of babies with gastroschisis to other parts of Tanzania. METHODS: We used a Step-Wedge Implementation Science design to scale up gastroschisis care through training of providers, dissemination and current revision of evidence-based care protocols, advocacy, and engagement with stakeholders. We used mixed methods for data collection. Anonymous patient and provider evaluation data were collected using a nationwide Gastroschisis Database via REDCap. We evaluated the implementation and effectiveness of the care bundle in different hospitals in Tanzania. RESULTS: Decentralizing care nationally was feasible, acceptable, and adaptable. A total of nine trainings have been conducted training 420 providers (14 Master Trainers) reaching seven regions of Tanzania. The three advocacy national campaigns have ensured community reach and patient engagement. A countrywide gastroschisis database was developed to collect data on patients with gastroschisis, hosted locally at MNH with 332 patients' data entered in 1 year. The majority (90.2%) were treated using preformed silo bags with an overall survival of 28.5% in all centers. Late presentation and infection remain to be the main challenge. CONCLUSION: To achieve quality and sustainable surgical care, there is a need to design, implement, evaluate, and continuously improve context-relevant strategies to achieve and sustain the survival of neonates with congenital anomalies. Decentralization enables clear connectedness of hospitals, bringing care closer to patients.

Perinatal outcomes of antenatally diagnosed omphalocele and gastroschisis: a survey from a university hospital.

Objective: To evaluate the clinical features and perinatal outcomes of antenatally diagnosed fetuses with omphalocele and gastroschisis. Material and Methods: This was a retrospective, single-center, cohort study of prenatally diagnosed fetuses with omphalocele and gastroschisis followed-up and delivered at a university hospital. Demographic, pregnancy, birth and perinatal outcomes were compared between gastroschisis and omphalocele. Results: A total of 75 fetuses with omphalocele and 21 cases with gastroschisis were evaluated. The mean maternal age of women carrying a fetus with omphalocele was significantly higher than the women with gastroschisis (p=0.001). Associated structural anomalies were found in 53.3% and 4.7% of fetuses with omphalocele and gastroschisis, respectively (p<0.001). The rate of chromosomal anomaly was 8.3% in pregnancies with omphalocele. In liveborn pregnancies, the mean gestational age at delivery and birth weight did not differ between the study groups. Time to postoperative oral intake, duration of parenteral nutrition and length of hospital stay were significantly longer in babies with gastroschisis than omphalocele (p<0.01). Rates of termination, intrauterine, neonatal and infant death of fetuses with omphalocele were 25.3%, 6.7%, 10.7% and 2.7% respectively. Time to postoperative oral intake, duration of parenteral nutrition and duration of hospitalization were significantly longer in babies with complex compared to simple gastroschisis (p<0.01). Survival rates were 95.2%, 82.9% and 20% in fetuses with gastroschisis, isolated and non-isolated omphalocele, respectively. Conclusion: Associated structural and chromosomal anomalies were significantly more common in fetuses with omphalocele compared to those with gastroschisis. Prognosis of fetuses with omphalocele depended on the associated structural and chromosomal anomalies, whereas bowel compromise was the main determining factor in gastroschisis.

Descriptive epidemiology of gastroschisis in China from 2007 to 2020: a nationwide surveillance-based study.

BACKGROUND: Gastroschisis is a common abdominal wall defect that increases infant mortality risk and health care costs. However, recent epidemiological data on gastroschisis in China is limited. METHODS: Using 2007-2020 data from the Chinese Birth Defects Monitoring Network (CBDMN), we analyzed gastroschisis prevalence rates stratified by birth year, maternal age group, residence area, geographical region, and infant sex. We also examined the temporal variations in prevalence, pregnancy outcomes of affected infants, prenatal diagnoses, and co-occurring anomalies. RESULTS: From 2007 to 2020, a total of 6,813 cases of gastroschisis were identified among 25,909,000 births, comprising 4,675 isolated and 2,138 non-isolated cases. Prevalence rates per 10,000 live and still births were 2.63, 1.80, and 0.83 for the overall, isolated, and non-isolated gastroschisis, respectively, all showing a decreasing trend over the study period. The prevalence of overall gastroschisis varied significantly by maternal age (< 20 years, 9.88/10,000; 20-24 years, 4.17/10,000; 25-29 year, 2.08/10,000; 30-34 years, 1.88/10,000;≥35 years, 2.24/10,000), maternal residence (urban, 2.45/10,000; rural, 2.85/10,000), geographic region (central, 2.54/10,000; east, 2.57/10,000; west, 2.80/10,000), and infant sex (male, 2.13/10,000; female, 1.79/10,000). Non-isolated gastroschisis cases had a higher early neonatal mortality rate than isolated cases (41.91% vs. 28.10%) and frequently co-occurred with musculoskeletal anomalies. CONCLUSIONS: This study highlights a declining trend in gastroschisis prevalence in Chinese population, a contrast to previous studies, and underscores the need for improved perinatal management due to adverse pregnancy outcomes associated with this condition.

Association Between Self-Reported Infections and Seropositivity Among Pregnant Women With Gastroschisis: A Case Control Study, With Emphasis on Chlamydia trachomatis.

BACKGROUND: Gastroschisis is a birth defect with the greatest risk among women <20 years of age. METHODS: Pregnant women attending the University of Utah's Maternal-Fetal Medicine Diagnostic Center between 2011 and 2017 for either their routine diagnostic ultrasound or referral were recruited (cases: pregnant women with fetal gastroschisis, n = 53 participated/57, 93%; controls: pregnant women without fetal abnormalities, n = 102 participated/120, 85%). A clinic coordinator consented and interviewed women and obtained a blood sample and prenatal medical records. We evaluated self-reported maternal characteristics, risk factors, and infections. To assess pathogen seropositivity we used Serimmune's Serum Epitope Repertoire Analysis validated 35 pathogen panels and Chlamydia trachomatis and compared seropositivity to self-report and prenatal medical record screening to assess sensitivity. RESULTS: Cases were more likely to report a younger age at sexual debut (p = <0.01), more sexual partners (p = 0.02), being unmarried (p < 0.01), changing partners between pregnancies (p = <0.01), smoking cigarettes (<0.01), and a recent sexually transmitted infection (STI) (p = 0.02). No differences were observed for self-report of illicit drug use or periconceptional urinary tract infections. Cases had a higher seropositivity for cytomegalovirus (p = 0.01). No differences were observed for herpes simplex I, II, or Epstein-Barr. Though based on small numbers, C. trachomatis seropositivity was highest in cases (17%) compared to controls (8.8%) with the highest proportion observed in case women <20 years of age (cases 33%; controls 0%). Any STI (self-report or seropositivity) was also highest among cases <20 years of age (cases 47%; controls 0%). Among C. trachomatis seropositive women, self-report and prenatal medical record sensitivity was 27.8% and 3%, respectively. CONCLUSIONS: Cases were more likely to engage in behaviors that can increase their risk of exposure to sexually transmitted pathogens. Case women <20 years of age had the highest proportion of C. trachomatis seropositivity and any STI. Prenatal medical records and self-report were inadequate to identify a recent chlamydial infection whereas, the SERA assay is a novel approach for evaluating subclinical infections that may impact the developing embryo.

Case Report of a Neonate with Complex Gastroschisis: A Multidisciplinary Approach.

Gastroschisis is a congenital anomaly characterized by herniation of abdominal contents via a defect in the anterior abdominal wall. Gastroschisis can manifest as simple or complex, with additional complications such as atresia, perforation, ischemia, necrosis, or volvulus. While prenatal screening and advancements in surgical techniques have improved outcomes, infants with complex gastroschisis cases pose significant challenges in neonatal care. Vanishing gastroschisis, a rare but dreaded complication with a mortality rate ranging from 10 to 70%, occurs when the abdominal wall closes around the herniated bowel, leading to strangulation. We present a case report focusing on the management of neonatal gastroschisis in a 36-week-old female infant with vanishing gastroschisis. The infant's clinical course, including surgical interventions, complications, and multidisciplinary management, is discussed in detail. This case underscores the importance of a multidisciplinary approach in optimizing outcomes for infants with complex gastroschisis. Via this case report, we aim to provide insights into the complexities of neonatal gastroschisis management and advocate for a collaborative approach involving neonatology, pediatric surgery, infectious disease, and palliative care to improve outcomes and quality of life for affected infants.

Evaluation of gastroschisis feeding protocol: A retrospective cohort study.

AIM: The primary objective of this study is to determine the impact of a standardised feeding protocol for infants with gastroschisis on early enteral feeds, suck feeds, management of gastric residuals and breastfeeding at discharge. Secondary objectives were evaluation of growth, length of stay in neonatal intensive care unit (NICU), the duration of total parental nutrition (TPN), blood-culture confirmed sepsis and serum bilirubin level (SBR). METHODS: This single-centre retrospective quality improvement project included infants admitted to a quaternary care NICU for management of gastroschisis from 2010 to 2021. The Gastroschisis feeding protocol, a standardised pathway for managing the feeding of infants with gastroschisis, was implemented in this NICU in 2016. The outcomes of infants in the pre-feeding protocol and post-feeding protocol groups were compared. RESULTS: Of the 100 infants included in the study, 49 were in the post-feeding protocol group. The baseline characteristics of the study population did not differ statistically in both groups. In post-feeding protocol group, there was significant reduction in the time to the first enteral feed (P value <0.0001) and first suck feed (P value = 0.002). The median length of stay in the post-feeding protocol group was significantly lower by 11 days (P value = 0.001). Duration of TPN was 241 h higher in the pre-feeding protocol group (P value 0.0007). CONCLUSIONS: Implementation of a feeding protocol in infants with gastroschisis led to earlier initiation of enteral feeds and suck feeds. There is a likelihood of reduction in the use of TPN and duration of admission in NICU.