Different Feeding Methods After Pyloromyotomy
Condition: Emesis
Study type: Interventional

Summary: 
      The objective of this study is to scientifically evaluate the ability to discharge patients
      based on feeding schedule comparing ad lib feeds to our current scheduled regimen.

      The hypothesis is that patients may be able to be discharged sooner with ad lib feeds.
    

Detailed description: 
      Hypertrophic pyloric stenosis is a common disease occurring in 2 per 1,000 live births1.
      Pyloric stenosis is a hypertrophy of the pyloric muscle which prevents emptying of the
      stomach leading to gastric outlet obstruction. The vomiting that ensues becomes projectile
      and results in severe dehydration. Traditionally this has been repaired with the
      pyloromyotomy via a transverse incision in the right upper quadrant. In the last decade the
      investigators have started doing the same procedure laparoscopically. Most institutions
      follow similar guidelines as to what constitutes a hypertrophic pyloric channel, initial
      electrolyte management and resuscitation prior to surgery, as well as the pyloromyotomy
      (either open or laparoscopically).

      Historically patients were fed the day after surgery, then 6 hours, and currently the
      investigators wait 2 hours after surgery to start feeds. The investigators go through a
      protocol of 2 rounds of clear liquids, 2 rounds of half strength formula/breast milk then 2
      rounds of full strength. Some centers have advocated ad lib feeds where babies go straight to
      full strength as tolerated when awake from the operation.

      Institutional variability is even further confounded by individual attending variability in
      some instances. Recent articles in the past two decades still prove that no consensus has
      been found. Some institutions profess that Ad Libitum feeding is both cost-effective as well
      as safe, but very few institutions to our knowledge follow this mantra. Others demand that no
      feeds should be started within 4 hours post surgery stating that the increased vomiting
      associated with this early feeding regimen actually prolongs the time to full feeds due to
      anxiety and discomfort. What has been shown is that no matter whether patients start 4 hours
      post surgery or wait 18 hours the time to full feeds is the same. All of these studies are
      hindered by the fact that they all have retrospective components to their design.

      What has also been propagated in two recent retrospective reviews is the implementation of
      clinical pathways as well as standardized feeding regimens. Both of these showed a decrease
      in length of stay postoperatively as well as hospital costs.

      At our institution a clinical pathway and feeding regimen has been implemented. The feeding
      regimen contrary to some of the previously quoted papers starts at 2 hours with sequential
      feeding increases. A prospectively acquired dataset at our institution has shown that emesis
      is correlated to the degree of dehydration of the child prior to surgery even with all the
      children being on the same clinical pathway.

      What all of these studies show us is that as a profession, Pediatric Surgery does not have
      the proper evidence to support any one post-op feeding regimen.
    

Intervention name(s): ad lib feedings after pyloromyotomy; FLAP diet after pyloromyotomy
Intervention type(s): Other; Other
Intervention description(s): ad lib feedings after pyloromyotomy; FLAP diet after pyloromyotomy
Other intervention name(s): post surgical refeeding ad lib; Post surgical FLAP refeeding
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: pyloric stenosis