Aspirating and monitoring gastric residuals from gavage feeds in preterm newborns is common practice in the NICU. The aim of this practice is to guide the advancement of gavage feeds to enteral feeds. However, even today, we still cannot say with certainty whether or not this practice improves neonatal outcomes.
A 2019 systematic review published in the Cochrane Database of Systematic Reviews set out to assess the efficacy and safety of refeeding as opposed to discarding gastric residuals in preterm infants. This study is important because it is the first systematic review to be performed on the risks and benefits of refeeding gastric residuals to preterm newborns.
The study
This systematic review was necessary because we do not have evidence-based guidelines or a consensus statement available to answer this question. The study conducted a subgroup analysis on an unblinded, randomized controlled trial of 72 preterm infants. This trial was the only randomized controlled trial of preterm newborns available for analysis.
Ultimately, the researchers concluded that the quality of the evidence gathered from this limited data was insufficient to support or refute the refeeding of gastric residuals to preterm infants. They were unable to say whether or not the refeeding of gastric residuals affects crucial neonatal efficacy outcomes such as
- Time to regain birth weight
- Duration of total parenteral nutrition
- Time to reach enteral feeds
- Length of hospital stay
- Presence of extrauterine growth restriction at discharge
- Growth at discharge and post-discharge
- Post-discharge neurodevelopment
The researchers were also unable to report whether or not the refeeding of gastric residuals affects neonatal safety outcomes such as
- Number of feed interruptions greater than or equal to 12 hours
- Incidence of stage 2 or 3 necrotizing enterocolitis
- Incidence of spontaneous intestinal perforation
- Mortality before discharge
- Incidence of post-discharge parenteral nutrition-associated liver disease
The theoretical risks and benefits of refeeding gastric residuals
The study’s subgroup analysis was designed to examine the many factors that are taken into consideration when deciding to refeed gastric residuals to preterm newborns, including
- Gestational age
- Birth weight
- Milk type: formula milk or human milk
- Quality of the gastric residual (bile-stained residual, curdled milk, or fresh milk)
- Volume of the gastric residual
- Whether the gastric residual volume is included in the volume of the next feed or not
Upon taking these factors into account, the NNP can then decide to refeed the gastric residual or not. Does the residual appear to be normal? If so, it might be best to refeed it to the infant, as it contains gastric acid, gastrointestinal enzymes, hormones, and partially digested milk that aid in the newborn’s digestion and development.
If the residual appears to be abnormal, that is, if it is of increased volume or altered appearance, many NNPs feel it is best to discard it, as refeeding it is thought to contribute to emesis, necrotizing enterocolitis, and sepsis.
How can we answer this age-old question?
Without a definitive answer to this age-old question, many NNPs resort to their unit’s protocol, physician advice, or their own experience in deciding whether or not to refeed gastric residuals to preterm infants.
The Cochrane study has an answer to this question, but it’s not the one we were hoping for. Since the quality of the available randomized controlled trial data was very low, the researchers recommend that a large, randomized controlled trial be performed. Such a trial could allow for quality evidence to be gathered that could better inform current neonatal practice.
