Re‐feeding versus discarding gastric residuals to improve gr | Figure 1

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Re‐feeding versus discarding gastric residuals to improve growth in preterm infants

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Monitoring of stomach aspirates to diagnose feed intolerance and necrotising enterocolitis is a common practice for preterm infants on tube feeds. There is no consensus on whether to re‐feed or discard the stomach aspirates. Although re‐feeding the aspirates may replace partially digested milk and gastrointestinal secretions that are essential for gastrointestinal maturation, re‐feeding abnormal aspirates may result in vomiting, necrotising enterocolitis, or sepsis. We have looked for evidence from clinical trials that assessed whether re‐feeding stomach aspirates is beneficial or harmful in preterm infants.

Study characteristics

The thorough literature search is up‐to‐date as of Febraury 2018. We found only one small randomised controlled trial (with 72 preterm infant participants) that addressed this question.

Key results

We are uncertain as to whether re‐feeding stomach aspirates has an effect on important outcomes such as incidence of necrotising enterocolitis, mortality before discharge, time to regain birth weight, time to reach full enteral feeds, duration of parenteral nutrition and duration of hospital stay.

Quality of evidence

Available evidence is insufficient to support or refute re‐feeding of stomach aspirates in preterm infants. More trials are needed to examine whether re‐feeding the stomach aspirates is beneficial or harmful in preterm infants.

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\ \ Does routine monitoring of stomach aspirates (partially digested milk and gut hormones withdrawn from the feeding tube) avoid necrotising enterocolitis in premature babies?\ Key messages\ Necrotising enterocolitis is a serious intestinal disease in premature babies that causes damage and death of gut tissue and may result in a hole in the intestine.\ • Routine monitoring of stomach aspirates to decide on feeding in premature babies probably has little or no effect on the risk of necrotising enterocolitis.\ • Monitoring stomach aspirates probably increases the time taken to reach full feeds, duration of parenteral nutrition (feeding through a vein) and the risk of infections. It may increase the time taken to regain birth weight and feed interruption episodes (time frames when feeds are stopped temporarily) in premature babies. The effect of stomach aspirates monitoring on other important outcomes is uncertain.\ • There is uncertainty whether using two different criteria of stomach aspirates to interrupt feeds has an effect on important outcomes in preterm infants.\ What did we want to find out?\ We wanted to look for evidence from studies that assessed whether routine monitoring of stomach aspirates is beneficial or harmful in premature babies.\ What did we find?\ We included five studies (423 babies) in this review.\ We found four studies on 336 premature babies that compared routine monitoring versus no monitoring of stomach aspirates in premature babies. We found one study comparing the usage of two different sets of criteria based on quantity and quality of stomach aspirates to decide on interrupting feeds while monitoring stomach aspirates.\ What are the limitations of the evidence?\ We are moderately confident about the evidence on the effect of monitoring stomach aspirates on outcomes such as necrotising enterocolitis, risk of infections, time taken to reach full feeds, and duration of parenteral nutrition.](https://app.figure1.com/case-detail/0e3a8dc0-7d53-4263-b27f-8fcfbcf24f64)

\ \ Cochrane Review; seven trials with 590 infants; comparing feeding with nutrient‐enriched formula to standard formula.\ Background\ Standard formula (designed for term infants) may not provide preterm infants with sufficient quantities of nutrients to support optimal growth and development. Nutrient‐enriched formula (with extra protein and energy from carbohydrates or fat and other nutrients) has about 20% higher nutrient content than standard formula.\ Key results\ Nutrient‐enriched versus standard formula for preterm infants does not reduce the time taken to regain birth weight but is associated with higher rates of weight gain and head growth (although not length gain) during neonatal unit stay after birth. Only limited data are available for growth and developmental outcomes assessed beyond infancy, and these do not show consistent effects. No evidence suggests other potential benefits or harms of nutrient‐enriched formulas, including effects on feeding or bowel problems.\ Conclusions\ Although available trial data show that nutrient‐enriched formulas increase growth rates of preterm infants during their initial hospital admission, they do not provide evidence of effects on longer‐term growth or development. Further randomised trials would be needed to resolve this uncertainty.](https://app.figure1.com/case-detail/1924883b-73c9-4165-80eb-21d681577cdd)

\ \ Review question\ In preterm or low birth weight infants receiving gavage tube feedings, does push tube feeding compared with gravity tube feeding result in increased adverse events (low oxygen saturation, low heart rate, time to full suck feeding).\ Background\ Infants born prematurely (before 37 weeks) may be unable to co‐ordinate sucking, swallowing, and breathing, and require gavage feeding. In gavage feeding, milk is delivered intermittently through a tube passed via the nose or the mouth into the stomach. Intermittent bolus milk feeds may be administered by using a syringe to gently push milk into the infant's stomach (push feed). Alternatively, milk can be poured into a syringe attached to the tube and allowed to drip in by gravity (gravity feed).\ Study characteristics\ The search is up‐to‐date as of July 2020. We included one study (31 infants) in this updated review.\ Key results\ Evidence is insufficient to show whether use of push compared with gravity gavage feeding results in more rapid establishment of full gavage feeds without increasing adverse events in preterm or low birth weight infants, or both, who require intermittent bolus gavage feeding.\ Certainty of evidence\ Evidence from randomised trials comparing push versus gravity intermittent gavage tube feeding in preterm or low birth weight infants (less than 2500 grams) is insufficient to inform practice.](https://app.figure1.com/case-detail/40a89a04-f6a0-4c75-af62-b80b979fd054)

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