Evaluation of Gastric

Residuals:
Efficacy and Impact on
Enteral Intake of Preterm
Infants in the NICU
Celine Marcotte
Sodexo Dietetic Internships – August, 2019
Why Preterm Infants?
 Critically ill patients

 NICU rotation

 Vulnerable population

 Unable to advocate for themselves

 Nutrition is at the forefront of care

 By the end of this presentation….
1. Participants will be able to explain the importance of
enteral nutrition in the preterm infant for optimizing
health outcomes.
2. Participants will be able to explain the effects, the
Objectives omission, or routine practice of gastric residual
evaluation has on the overall nutritional status of
preterm infants based on current research.
3. Participants will be able to translate and describe
the results of this current research into clinical
practice by continually advocating for the
optimization of nutrition in critically ill patients.
  NICU = Neonatal Intensive Care Unit
 GA = Gestational Age
 LBW = Low Birth Weight
 VLBW = Very Low Birth Weight
 ELBW = Extremely Low Birth Weight
 GI = Gastrointestinal
Abbreviations  AC = Abdominal Circumference
 NEC = Necrotizing Enterocolitis
 EN = Enteral Nutrition
 PN = Parenteral Nutrition
 GR(V) = Gastric Residual (Volume)
 LOS = Length Of Stay
 NPO = Nil Per Os (nothing by mouth)
 Any infant born prior to 37 weeks gestation1
 Extremely preterm (<28 weeks)
 Very preterm (28-32 weeks)
 Moderate to late preterm (32-37 weeks)
What is a  Early term (37-39 weeks)
Preterm
Infant? Weight Categories1
 LBW (<2500 g)  5 ½ lbs
 VLBW (<1500 g)  ~3 lbs 5 oz
 ELBW (<1000 g)  ~2 lbs or less...
 The Healthy People 2020 goals
are to reduce preterm birth rates
to no more than WHAT % of live
births?2
Test your
Knowledge A: 9.4%
B: 17.5%
C: 13.2%
D: 4.8%
Preterm Birth
Rates in the
U.S
  The NICU is arguably one of the most
important areas to provide adequate nutrition1
 Higher nutritional needs
 Daily growth
Introduction –  Reaching “full feeds”
What is  Minimal muscle and fat – insufficient energy
stores
already known  Essential for growth, metabolism, and immunity
 Improves neurological and cognitive outcomes
 Micronutrient needs that mimic intrauterine
growth patterns1
3
 Providing PN is considered a standard of
care for extremely preterm infants1
 Indications:
 GI malfunction or failure and immaturity of
bowel function1
Means of
 “Bridge PN”
Providing  Generally agree <32 weeks’ gestation and/or a
Nutrition birth weight <1500 g1
 Duration usually 1-2 weeks

 EN is added and PN is tapered down as infant

tolerates more feedings
  Necrotizing Enterocolitis (NEC)
 Serious and potentially fatal illness in which the colon
becomes inflamed, severely infection and with tissue death
in parts of the colon4
 Hold EN, IV antibiotics, surgery

Barrier to  Causes:
Providing  Immature lungs and intestines
 Inadequate movement of blood and oxygen
Adequate  Difficulty breaking down food/fighting infection4
Nutrition
 Risks: high risk preemies fed formula by mouth or tube

 Symptoms: swollen and bloated belly (red), apnea, feedings

that stay in the stomach, green fluid in stomach, perforation
of intestines, and bloody stool4
If NEC is present, EN is often held
and PN is initiated instead
  Standard of care in most NICUs

 Checking GRV thought to accomplish several

The Role of tasks
 Confirm placement
Gastric  Monitor residuals before feedings
Residuals
 Residuals are checked prior to administering EN
feedings
 Abnormal residuals: >2 ml/kg per feeding or >50%
of the previous feeding volume5
 Unfortunately, very little information exists
regarding the risks and benefits6
 Wide variability in practice
 GR color
Lack of  Frequency
Evidence and  What happen to the GRs that are drawn?
Standards Issues with checking GRs:
 Interrupts feedings
 Residuals are often discarded7
 Delays progressions to full feedings
 Can lead to prolonged use of PN7
  First to assess the value of routine GR evaluation in a
randomized prospective manner
Value of
Routine Gastric  Compare the amount of feedings achieved at 2 and 3
Residual weeks of age and the number of days to reach full
Evaluation in feeds
VLBW infants
 Characteristics: 61 VLBW infants
Torrazza et al.7  <32 GA
January, 2015  <1250 g
 Able to take some EN by 48 hours of birth
  Study Design: Randomized Control Trial
 Group 1 (n=30): Received routine GR evaluation (RGR)
 Group 2 (n=31): Did not receive routine GR evaluation
(NGR)

 Exclusion Criteria: Congenital abnormalities or GI

Study Design malformations
 Primary Outcomes: EN intake at 2 weeks to reach 120
ml/kg/day
 Secondary Outcomes: EN intake at 3 weeks, days to reach
150 ml/kg/day, growth measurements at 3 weeks, days
with PN and central line, and incidence of NEC
  Primary:
 No significant
difference in EN at 2
weeks
 Secondary:
 No significant
difference between
RGR and NGR groups
Outcomes  Time to reach full
feeds of 150 ml/kg/day
occurred sooner in
NGR
 Length of time on PN
shorter for NGR group
 No difference in
incidence of NEC
  Confers no benefit in performing routine GR
evaluation in otherwise asymptomatic
preterm infants7

 States that there appears to be insufficient

Findings evidence to support or refute its use7

 Although not statistically significant, NGR

groups reached full feedings earlier and
required fewer days of PN and central access7
 Clinical significance
  Researching alternatives to measure feeding intolerance other
than GRs
Abdominal
Circumferences  First to systemically evaluate the usefulness of alternatively
measuring AC
as a Measure of  >2 cm diameter considered abnormal

Feed  Compare AC and GRV prior to feedings as a measure of feed

Intolerance intolerance

 Characteristics: 80 VLBW infants

Kaur et al.8  Born between 27-34 weeks
February, 2015  <1500 g
 Hemodynamically stable
  Randomized Control Trial

 Primary Outcomes: Time

taken to achieve full feeds
with tolerance for at least
24 hours
Study
Design  Secondary Outcomes:
Incidence of feed
intolerance, days taken to
regain birth weight, feed
interruption days, days on
PN, LOS, and incidence of
NEC and sepsis
  Primary:
 Significant difference
between groups in time
to reach full feeds
 Secondary:
 Significant difference
Outcomes between feed
intolerance
 GRV group with feed
interruptions for 1-3
days NPO
 Duration of PN
significantly more than
the AC group
  AC group measured for feed intolerance resulted in
fewer feed interruptions and reached full feeds 4
days earlier than those who received routine GR
evaluations8

Findings  The number of feed interruption days and duration

of PN were also significantly less in the AC group8
 Clinical significance

 Potential preferred tool over GR evaluation8

  Researched the effect of selective versus routine GR
Impact of evaluation
Routine  Selective if showed signs/symptoms
Gastric
 Reviewed outcomes of infants after discontinuing routine
Residual GR evaluation prior to feedings and compared with a
historic control group
Evaluation on
Achieving Full
 Looked at time to reach full feedings and incidence of NEC
Enteral Feeds
 Characteristics: 472 preterm infants
Riskin et al.9  <34 weeks GA for 2 years before/after the change
May, 2017
  Study Design: Retrospective Study
 Group 1 (n=239): Historic ”control” group who
received routine GR evaluation
 Group 2 (n=233): Study group who did not receive
routine GR evaluation prior to feedings

Study Design  Exclusion Criteria: Congenital abnormalities and

critical illness
 Primary Outcomes: Time taken to achieve full feeds of
150 ml/kg/day with tolerance
 Secondary Outcomes: Incidence of NEC, number of
NPO and PN days, age at full feeds, LOS, and weight
at discharge
  Primary:
 Significant difference
of time to reach full
feeds
 Secondary:
 Significant difference in
days requiring PN,
younger age at full EN
Outcomes feeds and weight gain
 Time to full PO feeds
and LOS showed no
difference
 Rate of NEC less with
1.7% in selective GR
group versus 3.3% in
routine group (not
significant)
  Concurred safety of discontinuing routine GR
evaluation prior to feedings
 Addition of protocols to evaluate other signs of
feeding intolerance/signs of NEC9

Findings
 Contributed to earlier attainment of full
feedings and may decrease the number of NPO
and PN days without increasing the risk for NEC9
 Clinical significance
  Aimed to assess the effects GRVs have on
feeding advancements
Gastric
Residual  Evaluate the effect of not relying on checking
Volumes in GRs prior to feedings to expedite
Feeding advancements to full feedings versus routine
GR evaluation
Advancement
 Characteristics: 87 preterm infants
Singh et al.10  1500-2000 g
April, 2018  <48 hours old
 Required enteral feedings
  Study Design: Randomized Control Trial
 Group 1 (n=42): Control group that received routine GR
evaluation prior to feedings
 Group 2 (n=45): Did not receive routine GR evaluation
 Unless signs of intolerance, held until seen by
Physician

Study Design  Exclusion Criteria: Major congenital malformations or

surgical conditions interfering with feeding
 Primary Outcomes: Time taken to reach full feedings of 120
ml/kg/d based on body weight
 Secondary Outcomes: Time to regain weight, incidence of
sepsis and NEC, number of times feedings were discontinued
or not advanced for >24 hours
  Primary:
 No significant
difference of
time to reach full
feeds
 Secondary:
 No significant
Outcomes difference
between the
groups including
incidence of
sepsis and time
to regain birth
weight
 2 infants in
control group
developed
NEC/sepsis
  Not measuring GRVs prior to feedings was feasible in
preterm infants with a shorter time to reach full
feedings in both groups10
 Strict adherence to study protocol

Findings  Avoiding routine assessment of GRVs did not shorten

the length of time to advance to full feeds10
 No benefit to omitting this practice
 No evidence to support use in measuring tolerance
 No accepted consensus
 Based on RN experience, clinician decision,
protocols
  First adequately powered randomized control trial to
Effect of determine the risks and benefits of omitting GR evaluation
 Minimal evidence to support use
Omitting  Does omission cause harm?
Gastric  Aimed to determine the effect of omitting prefeed GRs on
Residual nutritional outcomes in extremely preterm infants
Evaluation on
Enteral Intake  Characteristics: 143 VLBW infants
 <32 GA
Parker et al.11  <1250 g
April, 2019  <72 hours old
 Able to take some EN
  Study Design: Randomized Control Trial
 Group 1 (n=74): Received prefeed GR evaluation
(residual group)
 Group 2 (n=69): Omitted routine GR evaluation (no
residual group)

Study Design  Exclusion Criteria: Congenital or chromosomal

abnormalities or GI malformations
 Primary Outcomes: Weekly EN measured in ml/kg for 6
weeks after birth
 Secondary Outcomes: Days to full feeds of 120
ml/kg/day, hours requiring PN and central line, growth,
days to discharge, and incidence of sepsis and NEC
  Primary:
 Significant
difference in
weekly increase
of EN

 Secondary:
Outcomes  No residual group
had higher mean
weight, fewer
episodes of
abdominal
distention,
shorter LOS
 No significant
difference for
developing NEC
or sepsis
 Contrary to
previous
studies, found
no difference in
length of time
PN or central
line was
required
  Infants who did not undergo GR evaluation received
considerably more EN
 Without increase in adverse health outcomes11

 With the omission of GR evaluation, infants advanced

feedings quicker, had fewer episodes of abdominal distension,
Findings consumed more EN at weeks 5 and 6 after birth, and were
discharged 8 days earlier11

 Overall, evaluating GRs is unnecessary and may decrease the

delivery of EN to extremely preterm infants
 “can be translated into evidence-based practice” for
VLBW infants11
  Routinely checking GRVs leads to delayed advancement to
full feeds, withholding feeds or providing less, residuals
being discarded, longer LOS, delayed weight gain, and
prolonged time requiring PN 7,9,11,12

 Use of GRs alone confers no benefit and other signs of

Conclusions intolerance should be used7,8
 AC possibly as a preferred tool

 Omission of GR evaluation increased delivery of EN,

improved weight gain and led to earlier hospital
discharge11
 Overall health/positive outcomes
  Evaluating GRs is unnecessary and may decrease the
delivery of EN
 Use other signs/symptoms of intolerance
 Optimize provision of nutrition
Conclusions
 Omission of routine GR evaluation had significant
results in Parker et al.’s study
 “can be translated into evidence-based practice” in
the care of preterm infants11
  Results should also cause one to continue to advocate for
optimal nutrition in all critically ill patients of varying ages

 Frequent holding of tube feedings with adult populations

for minimal residuals13
Application to  Poor outcomes for malnourished/critically ill patients
Clinical
Practice  ASPEN 2016 guidelines
 GR volumes should not be used as part of routine care to
monitor ICU patients receiving EN
 Holding feeds for <500 ml, in the absence of other signs,
should be avoided13
  Further studies involving ELBW infants versus only VLBW
infants

 Standard percent or ml/kg of gastric residuals that could be

Future used in all NICUs

Research
 Additional research to prove beneficial effects of omitting
GR evaluation to make it a standard of care in all NICUs

 Larger study populations

 References:
1. Hashim E. Nutrition for the Preterm Infant. PowerPoint. Boston Children’s Hospital.
https://www.dropbox.com/sh/ob4teye9pamb4t9/AACBwrk6QeKoPjCYqVwsyDd_a/Day%201%20Presentations?dl=0&p
review=6_Premature+Infant+w.answers.pdf&subfolder_nav_tracking=1. Published October 29th, 2018. Accessed August
3, 2019.
2. Healthy People 2020 Staff. Maternal, Infant, and Child Health: Latest Data. HealthyPeople2020.
https://www.healthypeople.gov/. Accessed August 10, 2019.
3. Stanford Children’s Health Staff. The first trimester. Stanford Children’s Health Hospital.
https://www.stanfordchildrens.org/en/topic/default?id=first-trimester-85-P01218. Accessed August 10, 2019.
4. Sickkids Staff. Necrotizing enterocolitis (NEC). AboutKidsHealth.
https://www.aboutkidshealth.ca/Article?contentid=1769&language=English. Accessed August 11, 2019.
5. Parker L, Torrazza RM, Li Y et al. Aspiration and evaluation of gastric residuals in the neonatal intensive care unit: state
of the science. Journal of Perinatal and Neonatal Nursing. 2015;29(1):51-E2. doi: 10.10.97/JPN.0000000000000080.
Accessed August 4, 2019.
6. Dutta S, Singh B, Chessell L et al. guidelines for feeding very low birth weight infants. Nutrients. 2015;7(1):423-442.
doi:10.3390/nu7010423. Accessed August 3, 2019.
7. Torrazza RM, Parker LA, Li Y et al. The value of routine evaluation of gastric residuals in very low birth weight infants.
Journal of Perinatology. 2015;35(1):57-60. doi:10.1038/jp.2014.147. Accessed July 7, 2019.
8. Kaur A, Kler N, Saluja S et al. Abdominal circumference or gastric residual volume as measure of feed intolerance in
VLBW infants. Journal of Pediatric Gastrointestinal Nutrition. 2015;60(2):259-63. doi: 10.1097/MPG.0000000000000576.
Accessed July 2, 2019.
Questions?