Routine Versus no Assessment of Gastric Residual Volumes in Preterm Infants

Study Overview
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Brief Summary
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The practice of checking gastric residuals is not evidence based. The amount of gastric residual volume (GRV) does not correlate with either feeding intolerance or development of NEC. We hypothesize that not monitoring GRV in infants with birth weights < 1,250 g, and who are being fed intermittently by gastric tube, will result in earlier attainment of full feeding. This is an unblinded randomized controlled trial where GRV will not be checked routinely in the intervention group.

Detailed Description
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The term gastric residuals in neonates refers to aspiration of gastric contents before each feeding in an infant receiving enteral feeding using an intermittent feeding tube. The presence of significant gastric residual volume (GRV) (Greater than 50% of the feeding volume) is a manifestation of delayed gastrointestinal maturation in a preterm neonate. The presence of GRV and its characteristics usually delays advancement of enteral feedings in premature infants because a large volume of undigested milk usually prompts the clinicians to hold the feeding. Advancement of early enteral nutrition is delayed or discontinued for >24 hours in nearly 75% of all extremely preterm infants. This is despite clinical evidence showing that early establishment of enteral nutrition is associated with reductions in the severity of critical illness, and long-lasting benefits on linear growth and neurodevelopmental outcomes. The magnitude and characteristics of GRV combined with specific findings based on abdominal examinations are usually considered by clinicians in decisions to continue with the scheduled enteral feeding plan. There are no studies to establish the normal volume of gastric residuals, its characteristics and whether routinely checking for them prior to each feed prevents necrotizing enterocolitis. A recent cohort study using retrospective controls showed that not monitoring GRV is associated with earlier attainment of full feeding in very low birth weight infants. Two small randomized studies conducted outside the United States and one study conducted in the United States showed no difference in outcomes when GRV are not checked routinely in preterm infants. These studies have several drawbacks and the practice of checking GRV continues. Study Objectives Primary Objective/Aim/Goal/Hypothesis The primary objective of this study is to demonstrate that not monitoring GRV in infants with birth weights < 1,250 g, and who are being fed intermittently by gastric tube, will result in earlier attainment of full feeding. Hypothesis: In preterm infants, changing the clinical practice from routine gastric residuals evaluation to no aspiration for gastric residuals will decrease the number of days to reach full enteral feeds. Secondary Objective/Aim/Goal/Hypothesis A secondary objective is to show that there will be no difference in the incidence of NEC (necrotizing enterocolitis) in the experimental vs the control group. Sample Size Determination Our NICU database shows that for infants <1,250 g the days to full feeding was 16.4 ±7.3 days. To detect a relative decrease of 20% in the experimental group will require 73 infants in each group with an alpha of 0.05 and a power of 0.8. Statistical Analysis Plan Primary Objective Analysis The primary outcome analysis is the number of days to reach full feeding volume, defined as volume > 120 ml/kg/d. This time will be compared between the two groups using analysis of variance. Secondary Objective Analysis Secondary analysis will be focused the frequency of feeding interruptions, incidences of NEC between the two groups using analysis of variance.

Official Title
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Routine Versus no Assessment of Gastric Residual Volumes in Very Low Birth Weight Infants Receiving Enteral Feeding Via Intermittent Feeding Tubes: A Randomized Controlled Trial.

Conditions
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Gastric Residual Volume, Preterm Infant, Feeding Disorder Neonatal

Intervention / Treatment
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* Other: No Gastric residual volume monitoring


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Birth weight ≤1250g Gestational age of < 33 weeks Expected to receive feeds via gastric tubes Exclusion Criteria: Death expected within 72 hours of birth Major chromosomal or congenital anomaly Major GI anomaly such as gastroschisis, spontaneous perforation etc.

Ages Eligible for Study
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Minimum Age: 2 Hours
Maximum Age: 1 Month

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Supportive Care
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Unblinded Single center Randomized controlled trial
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: GRV group<br>Gastric residuals will be checked prior to feeds | |
| Experimental: NO GRV group<br>Gastric residuals will not be checked prior to feeds | Other: No Gastric residual volume monitoring<br>* Gastric residual volumes will not be monitored<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Days to reach full enteral feeds | Days to reach enteral feeding volume of 120ml/kg/day | 1 month after enrollment | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Necrotizing enterocolitis | Stage 2 NEC and higher grade | Until hospital discharge, an average of 2-6 months | 
| weight gain | Weight gain velocity in gm/kg/d | 4 weeks chronological age and 36 weeks corrected gestation | 
| frequency of feeding interruptions | Number of timed feeds are withheld | Until full feeds are reached, usually between 2 weeks - 2 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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gastric residuals, feeding, very low birth weight infants